What works in improving integrated care for older people?

How can integrated care for older people in Europe be improved? The European project entitled SUSTAIN is concerned with this question. In this project, researchers, policy advisors and other partners from the current eight participating European countries analyse initiatives in the field of integrated care for older people living at home. This yields valuable insights.

SUSTAIN (Sustained tailored integrated care for older people In Europe) is a research project with fourteen existing European sites. Our role in this project is to research and disseminate knowledge. The National Institute for Public Health and the Environment (RIVM) and VU University Medical Center (VUmc) in the Netherlands are the initiators and coordinate the project.

Common bottlenecks

‘SUSTAIN is meant to look at existing initiatives, how they can be improved and how we can then disseminate this knowledge’, says SUSTAIN coordinator Caroline Baan of the RIVM. ‘We drew up the criteria that the initiatives had to meet. For example, they had to focus on older people living at home with a complex demand for care, and the initiatives must be willing to improve the current way of working. Points for improvement have been identified with managers, professionals working in the fields of care and welfare, municipalities, and representatives of older people and informal caregivers. They are based on several common questions, namely the following.’

How can we:
1. Ensure that professionals from welfare and healthcare domain improve their cooperation?
2. Improve the sharing of information?
3. Improve person-oriented care?
4. Involve older people in care?

Uniform research method

‘In all initiatives, improvement projects were implemented that focused on local bottlenecks’, says SUSTAIN project manager Simone de Bruin of the RIVM. ‘As researchers, we evaluated the implementation process. Interviews were held with older people, informal caregivers, managers and professionals. They were based on themes that are important for the European Union. Namely: how is attention paid to person-oriented work, safety, efficiency and prevention? But also: what went well within the improvement project and what did not?’

Determining factors

De Bruin: ‘The similarities in the results are striking. For example, we found that professionals and managers are often satisfied with the provided person-centred care. However, older people and informal caregivers often have different views compared to professionals about what person-centred care means. Some of the older people felt that their needs were not adequately addressed. They also did not know that they had a care plan, what they could do with it and how they could co-decide on the care. We also see similar factors that determine whether such an improvement process works. For example, it is important that care professionals speak the same language, that sharing information is facilitated and that there is leadership.’

Two types of improvement paths

Baan: ‘We encountered two different types of improvement programmes. One is mainly aimed at improving involvement of professionals from different organisations to become better acquainted. This leads to enhanced cooperation and communication. We have seen this especially in newer initiatives. In initiatives where cooperation is well-established, care and welfare professionals, volunteers and municipalities aimed to improve the care.’

Lessons learned in West-Friesland

The RIVM and VUmc were also engaged in the SUSTAIN project in West Friesland, one of the 14 initiatives. Baan: ‘This was primarily a first type of improvement process, where the improvements aimed to stimulate trust between professionals and getting to know one another better. This was done with visits to each other’s workplace and by attending joint intervision meetings. It helps to be aware that such processes take a lot of time. Furthermore, it is important that there is an initiator and that people of all layers in each participating organisation work well together. A challenge is to safeguard the improvements that have been made, also because there are many other developments in the region that require attention.’


At the beginning of 2019, the SUSTAIN consortium will deliver a roadmap designed by Vilans. This is a practical translation of all research findings. De Bruin: ‘The roadmap describes all the available tools and information. If managers and professionals want to start or improve an integral care process, they will find the key factors for success and the various steps that they can take in the roadmap. We will also share the lessons we have learned within SUSTAIN!’

In addition to Prof. dr Caroline Baan and Dr Simone de Bruin, Prof. dr Giel Nijpels from the VUmc is also involved in SUSTAIN.

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

More information

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