Embrace, an integrated elderly care model

Good practice:

Empower staff to shape development through the project lifespan

NORTHERN NETHERLANDS  / Embrace, an integrated elderly care model:  1136/1143 8/50

There is already talk of efficient care: more quality for the same cost. This is an important result.

Originally designed to solve single, acute, and mainly short-term diseases, today’s health care systems face difficulties in solving these challenges. Associated, ongoing specialisation and technological improvements have led to fragmentation of care delivery. The result is a substantial increase in health care expenditures. Structural and financial barriers have further increased the segmentation of organisations that provide primary and secondary care, health care, and social care.

Customer's need

Despite the wide array of health services, these older adults do not always receive appropriate and coherent care. This often leads to adverse drug events, difficulties with participation in treatment, and even treatment errors. Consequently, health care systems need to be transformed. Integrated care models promise to provide a solution to control these health care challenges, to enable elderly to live at home as long as possible in good health.

The solution

Embrace connects the health system with the community services, and reflects the four key elements of the Chronic Care Model (CCM):

  • Self-management support.
  • Delivery system design.
  • Decision support.
  • Clinical information systems.

Within the context of the community and health care systems, these four components are combined with the Kaiser Permanente (KP) triangle. This population health management model classifies older adults living in the community. 

The delivery system design includes Elderly Care Teams (ECTs). These multidisciplinary teams are led by the GP, and include an elderly care physician, a district nurse, and a social worker.

Keys to success

  • Patient centred, proactive and preventive care and support of an elderly care team for all older adults living in the community. This covers health problems related to the consequences of ageing (including body functions, activities, participation and environmental factors).
  • Annual screening and triage into risk profiles, and connecting a suitable care intensity level to these risk profiles.
  • Embrace was initiated, developed, implemented and evaluated by a variety of dedicated organisations: care providers, financiers of care and support, and research institutes.

Good practice: Empower staff to shape development through the project lifespan

Good practice description

Engaging with clinical staff early in the developmental process is important. ACT also identifies that this engagement should continue throughout the project lifespan. Most crucially, it is a process that allows staff to influence the ongoing development of programmes. 

Programmes within ACT that demonstrate good practice in staff engagement have mechanisms in place to ensure 360° communication and involvement. Staff are not simply told what to do or why they are doing it. They are encouraged to make comments and suggestions that can be incorporated into the ongoing development of programmes.

“ A ‘learning community’ with regular meetings to exchange ideas and knowledge between professionals and project leaders is a ‘professionals-centred’ method for improving integrated care."

Good practice example

The Embrace programme is one that demonstrates an ongoing approach to encouraging and acting upon frontline staff feedback. Not only are there regular meetings between project leads and frontline practitioners, but these are carried out in the spirit of partnership: a learning community 

Frontline staff are encouraged to give their views on the progress of programme and, where possible, this feedback is incorporated into future developments. Demonstrating some of the challenges of project management, it is not always possible for all staff suggestions to be taken forward.

The program

Embrace reflects four key CCM elements: Self-management support focuses on the elderly person’s central role in health management. This includes shared decision making, motivational interviewing, goal attainment, and action planning. Community meetings for participating elderly individuals are organised around the need for prevention. Emphasis is around enforcing a healthy lifestyle, as well as maintaining self-management abilities.

The district nurse or social worker, in the role of case manager, will navigate the elderly person through this complex processes. Organising appropriate care and support in the most efficient, effective, and acceptable way.

The GP and elderly care physician will manage the medical care for elderly people with multimorbidity. Monthly ECT meetings are scheduled, in which health problems and treatment options of elderly people and caregivers will be discussed and evaluated. Particular attention will be paid to the elderly person’s multimorbidity, polypharmacy, self-management ability, prevention, lifestyle, and future expectations. Decision support will be addressed through multiple decision support tools. A triage instrument is used for stratification. The second decision-support instrument is a structured history questionnaire. 

The clinical information systems will be represented by the Electronic Elderly Record System (EERS). This is a web based application built for both clinical and research purposes. The EERS includes personal health records that contain individual triage data, the history questionnaire, an individual care and support plan with information about goal setting, actions performed, and evaluations.

Contact information

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Dr. Klaske Wynia; Assistant professor for Integrated Care and Programme leader for Embrace


Program partners