To improve integrated care for older people, professionals and organisations need to get to know each other, build trust and better understanding. They should start with a small-scale project and have a shared vision for care for older people. These are the outcomes from the cross-European research project SUSTAIN on integrated care which has been completed this month.

RIVM and Amsterdam UMC (location VU University Medical Centre) coordinated the project. Thirteen established integrated care initiatives for older people living at home participated in SUSTAIN. Older people encounter many health and social care needs. Meeting these needs requires health and social care professionals to collaborate and coordinate care and support around older people’s needs. SUSTAIN researchers’ monitored improvement projects that were undertaken in the thirteen initiatives to understand what works and what does not work when improving integrated care. 

The initiatives were located in seven European countries and provided different types of care and support services. Although there were several differences between the initiatives, they encountered similar challenges: insufficient involvement of older people and informal carers in the care process and lack of information sharing between professionals. Researchers identified two types of improvement projects. On the one hand, projects focused on improving or expanding collaboration, communication and coordination between professionals, on the other hand, projects focused on improving the actual care delivery process, for instance providing care in a more person-centred way.

Different activities to improve integrated care were undertaken, for instance, the involvement of older people in the development of their care plans. Also, meetings for professionals to get to know each another’s roles and responsibilities to build trust and understanding were organised. To improve integrated care successfully, it is essential to start with small-scale improvements based on a shared vision and project goal and centred around users’ and informal carers’ needs.

The Horizon2020 research project also produced a ‘Roadmap’, which is designed as an improvement aid for managers of care organisations, professionals and policy-makers to support improving integrated care. The Roadmap describes steps for implementing and improving integrated care for older people and includes the lessons learned from the SUSTAIN project. On March 13 2019, the final conference took place in Brussels, where the SUSTAIN project findings were shared with policy-makers, health and social care professionals and researchers.