Evidence on integrated care is not only needed to show which interventions work, but also to understand how organisational processes affect these interventions. Therefore, evidence from large-scale implementations is especially important. In October 2015, the consortium of the EU-funded programme 'Advancing Care Coordination and Telehealth Deployment' (ACT) published a ‘cookbook’ of good practices, focusing on the structural and organisational drivers as well as barriers to large-scale deployment of care coordination and telehealth in five European regions. The report centres on chronic patients and elderly people, giving recommendations regarding staff engagement,  patient adherence, risk stratification and programme assessment. The report does not only look at health outcomes, but also economic outcomes such as the total cost per patient and the transition of resources towards primary care. An example of good practice from the Northern Netherlands is the programme Embrace. A core element of Embrace is the work of multidisciplinary teams led by a GP, which also comprise an elderly care physician, a district nurse, and a social worker. These Elderly Care Teams (ECTs) provide patient centred, proactive and preventive care and support to all older adults living in the community.

Source:

The Advancing Care Coordination and Telehealth Deployment (ACT) Consortium