The SUSTAIN Roadmap for integrated care is now available

The roadmap is a practical representation of SUSTAIN’s research findings and aims to improve integrated care for older people living at home. With this roadmap, policy and decision-makers will be able to design and improve integrated care in their own community.

In the SUSTAIN project (Sustainable tailored integrated care for older people in Europe), partners worked in close collaboration with health and social care staff from 2015 to 2019. 13 sites across 7 European countries were involved. Together, they have delivered several products, such as country reports and an overarching policy report, which provides insight into research findings on integrated care. The roadmap is the final product of this collaboration.

Like a cookbook

Researcher Nick Zonneveld: ‘If you look at integrated care as a soup and the Roadmap as a cookbook, there are generic ingredients, such as water, that need to be used. But there can also be many specific ingredients. This Roadmap enables decision-makers to compose the type of integrated care that works best for their own community.’

Key elements for well-organised integrated care

The research findings show that one such example of a generic ingredient is person-centred care. Other key elements are safeguarding dignity, coordination, and an interprofessional workforce. The Roadmap offers inspiration for how integrated care can be designed and improved by discussing examples from practice from the participating European countries.

Fragmented care

Although there are many organisations that currently offer integrated home care support, there is still room for improvement. The need for integrated care is caused by fragmented care. A problem which exists on an international scale. A family caregiver: ‘I feel that the current system is a labyrinth in which it is easy to lose continuity of care and which results in a higher risk of adverse events. With my mother, I experienced this situation where going to different consultations led to misinformation and duplication of medication.’


Integrated care is therefore a necessity for policy and decision-makers who want to improve care for older people. The SUSTAIN project contributed to two main objectives:

  1. To make the shift towards more person-centred, prevention-oriented, safe and efficient care for older people living at home with multiple health and social care needs.
  2. To contribute to the adoption and application of these improvements to other health and social care systems and regions in Europe. The roadmap is the outcome of this objective.

Final conference in Brussels

On March 13, the Roadmap was presented at the final SUSTAIN conference in Brussels to policy makers, health care professionals, researchers, and others involved in the care for older people living at home.

Five books

The roadmap (Pdf) contains 5 different books:

  1. Designing integrated care services. A guide that helps plan integrated care by outlining the key design features: person-centred, coordination, ‘empowering an interprofessional workforce’, and ‘safeguarding dignity’. In our subsequent articles we will address each one of these features separately.
  2. Setting up integrated care. A ‘how-to’ guide on managing change that supports key decision makers in the implementation process of integrated care.
  3. Improving integrated care. Helpful if you have already initiated the implementation process and want to improve integration. Read about the lessons leaned, tools and experiences of the SUSTAIN participants.
  4. Context of integrated care. Providing insight into how to develop an enabling environment. For instance, how do you build support for change and how do you develop collaborative capacity?
  5. Resources. A list of all references in each book, advocacy, assessment tools, as well as case stories and a factsheet on the case sites.

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

Contact for this project: