Hoedemakers Maaike, Marie Leijten Fenna Ruby, Looman Willemijn, Czypionka Thomas, Kraus Markus, Donkers Hanneke, van den Hende-Wijnands Esther, van den Broek Nicole M A, Rutten-van Mölken Maureen
Erasmus School of Health Policy and Management, Erasmus University Rotterdam, NL.
Institute for Advanced Studies, Vienna, AT.
Int J Integr Care. 2019 Sep 3;19(3):16. doi: 10.5334/ijic.4626.
Increasingly, frail elderly need to live at home for longer, relying on support from informal caregivers and community-based health- and social care professionals. To align care and avoid fragmentation, integrated care programmes are arising. A promising example of such a programme is the Care Chain Frail Elderly (CCFE) in the Netherlands, which supports elderly with case and care complexity living at home with the best possible health and quality of life. The goal of the current study was to gain a deeper understanding of this programme and how it was successfully put into practice in order to contribute to the evidence-base surrounding complex integrated care programmes for persons with multi-morbidity.
Document analyses and semi-structured interviews with stakeholders were used to create a 'thick description' that provides insights into the programme.
Through case finding, the CCFE-programme targets the frailest primary care population. The person-centred care approach is reflected by the presence of frail elderly at multidisciplinary team meetings. The innovative way of financing by bundling payments of multiple providers is one of the main facilitators for the success of this programme. Other critical success factors are the holistic assessment of unmet health and social care needs, strong leadership by the care groups, close collaboration with the healthcare insurer, a shared ICT-system and continuous improvements.
The CCFE is an exemplary initiative to integrate care for the frailest elderly living at home. Its innovative components and critical success factors are likely to be transferable to other settings when providers can take on similar roles and work closely with payers who provide integrated funding.
越来越多的体弱老年人需要在家中生活更长时间，依赖非正式照料者以及社区卫生和社会护理专业人员的支持。为了使护理协调一致并避免碎片化，综合护理项目应运而生。荷兰的体弱老年人护理链（CCFE）就是这样一个有前景的项目典范，该项目支持体弱且护理情况复杂的老年人在家中保持尽可能良好的健康状况和生活质量。本研究的目的是更深入地了解该项目以及它是如何成功实施的，以便为围绕患有多种疾病者的复杂综合护理项目的证据基础做出贡献。
通过文件分析和对利益相关者进行半结构化访谈，以创建一份能深入了解该项目的“详细描述”。
通过病例发现，CCFE项目针对的是最体弱的初级护理人群。体弱老年人参加多学科团队会议体现了以患者为中心的护理方法。通过捆绑多个提供者的支付进行创新融资方式是该项目成功的主要推动因素之一。其他关键成功因素包括对未满足的健康和社会护理需求进行全面评估、护理团队的有力领导、与医疗保险公司密切合作、共享信息通信技术系统以及持续改进。
CCFE是整合对在家居住的最体弱老年人护理的一个典范举措。当提供者能够承担类似角色并与提供综合资金的付款人密切合作时，其创新组成部分和关键成功因素可能会转移到其他环境中。
