3 activities that improve coordination on integrated care

Good coordination is one of the key features of successful integrated care for older people living at home. It brings together a range of services from the health and social care sectors and enables them to function together seamlessly. In this article, we discuss 3 activities that improve coordination.

These 3 activities are outlined in the Roadmap, a practical representation of the research findings of the European project, SUSTAIN. This collaboration addressed the question, ‘How to improve integrated care for older people in Europe who are living at home?’ Vilans was involved in the research. You can find the extended version of the feature ‘Coordination’ in book 1 of the Roadmap, ‘Design of integrated care.’


Research findings show that greater coordination of care has several benefits. These include reduced hospital and care home admissions, length of stay, and readmission rates. Coordination can also be important for vertical programs that focus on care for a particular disease or target group. It facilitates improved access to care, greater community satisfaction and improved health outcomes.


In order to provide good coordination, you must first ensure that the needs and preferences of people are assessed, a comprehensive care plan is developed with the user (client), and services are managed and monitored through an evidence-informed process.

The following key activities enhance coordination:

1. Case management – enables older people to live at home longer and reduces their frequency of visits to care facilities. Case management is a collaborative process of assessment, planning, facilitation, care coordination, and advocacy of and for the family’s health and care needs. The case manager has multiple tasks, among which are providing relational continuity of care, getting information from involved caregivers and taking accountability for the care provided.

A learned lesson from practice: it is important that case managers are respected and provided with a clear mandate to assume this role. This did not happen at the Mendedi site in Estonia, where the role of case manager was introduced as a nursing role. Certain factors limited their ability to execute their duties as a case manager, including professional cultures, as well as rules guiding referrals and prescriptions.

2. Joint care assessment – is a standardised protocol to explore the health and social care needs of the older person and his informal carer. A joint care assessment eliminates the need for people from different agencies to go through multiple assessments. Therefore, it provides a better care experience for the user. It seeks to address all the needs of the older person and how they can be met. Research findings show that comprehensive joint assessments are associated with improvements in the self-rated health and wellbeing of older persons, reductions in depression scores, reduced numbers of falls, and improved quality of life for those able to remain in their community or at home.

For instance, in the Swale ‘Home First’ service in the UK, a key element of the improvement project was to conduct a shared assessment at the user’s own home, rather than multiple assessments both in and out of hospital. This reduced the time that the older person normally would spend in an acute setting.

3. Care transition management – is a specific approach that supports users in making a well-managed return to home following discharge from a hospital. In addition, it helps the user and their informal carer with signaling if the user’s condition deteriorates, managing medications, maintaining and sharing personal health records, and enabling follow-up appointments and visits. Well-managed care transitions can significantly improve the health status of older people, increase their ability to live independently, as well as diminish costs.

A good example from practice: a large integrated delivery system in Colorado shows that improved transition management can help reduce readmissions. A Care Transitions Intervention reduced 30-day hospital readmissions by 30 percent, 180-day hospital readmissions by 17 percent, and cut average costs per user by nearly 20 percent.


In the European project SUSTAIN (Sustained Tailored Integrated care for Older People in Europe) researchers, policy advisors and other partners from eight participating European countries analysed initiatives in the field of integrated care for older people living at home. The Roadmap is their end-product and enables policy and decision-makers to design and improve integrated care in their own community.

The SUSTAIN project was funded under Horizon 2020 – the Framework Program for Research and Innovation (2014-2020).


Contact for this project: