Academic networks for more integration and more demand-driven care and support for people with complex needs

摘要

Background : In recent years several national ZonMw research programs in the Netherlands have focused on integrated care for people with complex care needs. Many different professionals and legal domains are involved, and there is a growing demand to deliver coherent care that is better suited to the clients needs. In different programs, researchers, health-care professionals and clients, work together in academic networks to establish integrated care. Elderly care and support : The Dutch National Care for the Elderly Program 2008-2017 stimulated integrated care for frail elderly. In eight regional networks, over 650 organizations joined forces in projects aiming to improve care and support that is better suited to the needs of elderly. Researchers worked together with general practitioners, nurses, community-workers, municipalities, health-insurers and elderly. In more than 200 projects over 40.000 elderly people participated. Elderly themselves performed an active role in agenda-setting panels and forums. The projects focused on different subjects such as early-detection of frailty, coordination of care and support at home, and patient journeys after hospitalization. Hospital at home : In the program Memorabel research projects aim for integrated care for people with dementia. Especially for this group of elderly, the hospital is a relatively unsafe environment. The hospital at home care program works with patients with dementia at the emergency department. Hospital level care delivered at home is compared to hospital care as usual. The goal is to investigate feasibility, costs and outcomes, such as time spend at home, quality of life, functioning and recovery. This study is conducted in a network of partners who cooperate in an action-research setting. Acquired brain impairment : The program Gewoon Bijzonder is intended for people with intellectual disabilities and their health care professionals. Experience experts, researchers, health care professionals and policy makers are stimulated to work together in networks. One of the networks focuses on NAH acquired brain injury gaining new knowledge on how people with NAH can function more independently in society. Results of the research will lead to better access of information, better participation of people with NAH in society and better care and support for people with NAH, their relatives and friends. Aims and Objectives : This workshop gives insight in how to work in academic networks of research, together with practice and policy on more integrated care on people with complex needs. Format timing, speakers, discussion, group work, etc :Three presentations will be given. One on the network-level and two on the project level. We will discuss the results with the target audience. Target audience : Researchers, health care professionals, clients and policy makers. Learnings/Take away : We will present a few examples on how to work on more integrated care on people with complex needs. We will discuss encountered issues, for example those concerning data sharing, measurement of patient satisfaction and interpretation of the results. And we will share learned lessons.