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Sustainable tailored integrated care for older people in Europe

Periodic Reporting for period 3 - SUSTAIN (Sustainable tailored integrated care for older people in Europe)

Reporting period: 2018-04-01 to 2019-03-31

The problem being addressed:
Population ageing and the economic crisis have put pressure on European health systems. It is not known what the best way is to respond to these challenges. In an increasing number of EU Member States, a diverse range of integrated care initiatives are being put in place as new models for safe and efficient, prevention-oriented care to an increasing number of older people.

Evidence of the effectiveness of integrated care is, however, inconclusive. Also there is little knowledge of how to successfully implement integrated care and of how to transfer successful initiatives to other regions and health systems. While integrated care is being rolled out and infrastructures are in place, improvements to existing initiatives are necessary to make them more patient-centred, prevention-oriented, efficient, and safe. Moreover, approaches are needed that actively and meaningfully engage all stakeholders and that optimally facilitate the transfer and uptake of best practice across contexts and countries.
The overall aims of SUSTAIN were twofold: 1. to improve established integrated care initiatives for older people living at home with multiple health and social care needs, ensuring they are patient-centred, prevention-oriented, efficient, and safe; 2. to ensure that improvements to the integrated care initiatives are applicable and adaptable to other health systems and regions in Europe.
The SUSTAIN project have last for 48 months and was divided into three interrelated phases (1. Preparation; 2. Implementation research to improve existing integrated care initiatives at selected sites and 3. Translation to products and impacts) covering eight interrelated work packages. We have finished the project. Since the start of the project, several activities within the relevant WPs have been carried out. During the preparation phase of the project (phase 1), we established working relationships with local stakeholders at fourteen integrated care sites across Europe (Austria, Estonia, Germany, Netherlands, Norway, Spain, United Kingdom). We further developed methodology for the baseline assessments at the integrated care sites, and actually conducted the baseline assessments to gain insight into the current way of working, how the SUSTAIN core themes (being person-centredness, prevention-orientation, safety and efficiency) were addressed and where improvements to the current way of working was undertaken. The results of the phase were described in country-specific reports and in an overarching European report. These outcomes have been discussed during stakeholder workshops at the sites, and discussions have taken place about how to improve the integrated care initiatives. During the implementation phase of the project (phase 2), local stakeholders designed and rolled-out improvement projects covering the areas for improvement identified in phase 1. SUSTAIN partners developed methodology to monitor and evaluate outcomes and progress of the implementation of the improvement projects. Data were collected at fixed points in time. All partners have analyzed their data, guided by templates to ensure uniformity in their approach. Parallel to the research activities, several dissemination activities have been taken place, including the development of the SUSTAIN website ( regular SUSTAIN newsletters, videos of local stakeholders from the SUSTAIN sites, flyers, and presentation of consortium partners at meetings and conferences. In addition, several activities have been taken place for the development of the roadmap, including the outline and design of the roadmap and case stories from the SUSTAIN sites.
Finally a analysis was completed, the roadmap constructed, all can be find on the website in different reports. Many activities have been taken place to communicate the findings by making use of social media and presentations at several international and national meetings.
The SUSTAIN project has been initiated from the noted shortcomings of the current approach to integrated care. In order to take integrated care to the next level, a novel approach is needed that draws on the strengths of Europe’s diversity but transcends the current limitations. The sample of fourteen integrated care initiatives in seven European countries offered a rich and varied view on diverse methods applied in a variety of specific contexts, that also diverge in their means of evaluating progress and generating evidence and useable knowledge. The Evidence Integration Triangle (EIT), developed as an arm of implementation science, provided a mechanism through which we realised our research ambitions. The first step, which was taken, was the design of a tailored set of improvements in each of the selected programmes. This step was followed by step 2, being a process of implementation with active participation from stakeholders, who have already been engaged in the design phase. The progress and outcomes of the implemented improvements have been monitored, and will provide insight in how they have affected the central criteria of person-centredness, prevention orientation, efficiency and safety. The monitoring allowed us the identification of facilitators and barriers (structural, organisational, cultural, professional, or otherwise), and the evaluation of what works and what does not, against what costs and time investments. Furthermore, the result is presented that it is transferable and can be adapted to other contexts. We provide a roadmap for integrated care improvement and innovation in Europe, providing a structured and practice-oriented manual to move towards more person-centred, prevention-oriented, efficient and safe integrated care for people aged 65 years and their carers. With such a roadmap in hand, the involvement of policy-makers and other forces shaping society is facilitated, and is input from ‘market forces’, ultimately benefitting clients.
sustain consortium