Neighborhood oriented Integrated care  for Vulnerable Older Adults

Background: In the Leuven region, we are witnessing a worrying trend: the number of older adults presenting at the emergency department has increased by 25% overall and by 40% in ambulatory attendances in 4years. Only about 30% of them were referred by a general practitioner. This might illustrate a broader systemic issue. Older adults with chronic or social vulnerabilities face fragmented, poorly coordinated care, causing inefficiencies, preventable hospitalizations, and loss of independence

 

Within Caring Leuven, our regional integrated care network, we aim to create a proactive, connected model of care. Vulnerable and frail older adults are a key focus group, representing a substantial part of the 5% population subgroup responsible for nearly half of all healthcare spending. By identifying vulnerability early and ensuring coordinated follow-up, we seek to improve quality of life and use resources more efficiently________________________________________

 

Approach: Our model combines population-based prevention with individualized care coordination, implemented through Integrated Neighborhood Teams (INTs). These small interprofessional networks connect primary care providers, social and community partners. They facilitate coordinated care delivery, ensuring that interventions are timely, person-centered, and aligned with the needs of the neighborhood.

 

At population level, INTs have started organizing proactive neighborhood screenings, in which older adults can voluntarily participate, to identify early signs of frailty, loneliness, or declining self-sufficiency. They promote healthy living and empowerment through community programs on nutrition, mental wellbeing, and fall prevention, helping older adults remain active and independent

At individual level, team members focus in their own practice on those who are already vulnerable. They are planning to do regular structured assessments across medical, functional, psychological, and social domains to identify areas requiring attention, detect early signs of deterioration, and support advance care planning When necessary, additional disciplines or services are involved to optimize support. These assessments will also generate valuable data that help us understand care needs, resource use, and outcomes across the population.

Over time we hope to be able to identify within each neighborhood, a group of high-need individuals to be followed more closely by a dedicated team or care coach, if possible in collaboration with volunteers and community initiatives. This low-threshold, proactive approach allows early intervention before crises occur.

 

Results and Next Steps:  The INT structure allows primary care to be reorganized into smaller, well-connected networks that improve coordination across care levels, and link with community based initiatives. Implementation of a transmural collaboration model for older adults, started already with offering direct access to geriatric advice and priority day hospital slots, reducing unnecessary emergency visits. Data from screenings will guide evaluation of outcomes such as crisis reduction, care efficiency, and wellbeing.

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Impact By integrating preventive community initiatives with structured individual follow-up, Caring Leuven is building a more connected and responsive healthcare system. The Integrated Neighborhood Teams promote proactive coordination, continuity, and prevention, while strengthening primary care capacity. Above all, this approach enhances autonomy, wellbeing, and quality of life, enabling vulnerable older adults to age safely and meaningfully within their own communities