Dynamic Networks for Person-Centered Integrated Care: A Personalized Integrated Care Approach

Background: People with complex needs require support across multiple interconnected life domains: social participation, mental wellbeing, meaning-making, and physical health. Most parts of current healthcare systems remain fragmented, with separate organizations focusing on single domains rather than the whole person. Dynamic networks that bring together diverse formal and informal caregivers offer a promising solution to deliver truly personalized, integrated care that responds to what matters most to individuals and their communities.

 

Approach: This practice-based initiative employed comprehensive co-design across three organizational levels, actively involving patients, informal caregivers, healthcare professionals, managers, administrators, funders, and students throughout:

- Micro-level (direct care): Co-created collaborative care arrangements with clients, informal carers, and diverse professionals, establishing dynamic networks around individual needs.

- Meso-level (organizational management): Developed structures and processes to organize, coordinate, and sustain dynamic networks across traditional organizational boundaries.

- Macro-level (systems and policy): Explored how accountability frameworks and financing mechanisms can support rather than constrain network-based care delivery.

 

Results: Engaging diverse stakeholders across multiple levels yielded important insights:

- Micro-level findings: Informal caregivers demonstrated strong motivation to participate when approached through a strengths-based lens focusing on their unique talents and contributions, rather than traditional duty-based frameworks. This inclusive approach enhanced network capacity and sustainability.

- Meso-level findings: Participants naturally adopted distinct but complementary generic roles within networks—'organizers' who coordinate activities, 'direct supporters' providing hands-on care, and 'indirect supporters' offering specialized input. Understanding these roles enables more intentional network composition and development.

- Macro-level findings: Significant tensions emerged around accountability. Current systems expect collective accountability from networks while maintaining individual responsibility frameworks unsuited to collaborative models. Existing accountability approaches proved unsustainable, particularly for informal caregivers, necessitating fundamental shifts toward shared, societal responsibility models.

 

Implications: This work provides practical frameworks for international delegates implementing community-based integrated care that strengthens workforce inclusivity and addresses inequalities:

• Operational guidance for establishing fluid, person-centered care networks across micro, meso, and macro levels
• Inclusive workforce strategies that recognize and leverage informal caregivers' talents alongside professional expertise
• Critical requirements for organizing sustainable dynamic care networks in diverse contexts
• Accountability innovation needs highlighting gaps between collaborative care realities and traditional governance structures
• Multi-level policy recommendations for local, regional, national, and European contexts to facilitate rather than impede dynamic network care

Further work continues on refining accountability features and developing enabling policies that support this collaborative, community-based model.