Figure 1
Framework for the conceptualisation of safety, showing the different domains of safety risks for older people living at home [23]. This framework was partly based on the principles of Lau at al.’s (2007) framework for health-related safety [19].
Table 1
Characteristics of thirteen integrated care sites participating in the SUSTAIN project (adapted from de Bruin et al., 2018 [7] and de Bruin et al., 2018 [28]).
| Country | Region | Integrated care site | Type of care services | Improvement project objective |
|---|---|---|---|---|
| Austria | Vienna | Gerontopsychiatric Centre | Dementia care | To improve detection of dementia and case- and discharge management of hospitalised people identified with a cognitive disorder. |
| Estonia | Ida-Viru | Alutaguse Care Centre | Home nursing and rehabilitative care | To develop a person-centred way of working by engaging older people, informal caregivers and a multidisciplinary care team in the process of defining a goal-directed care plan. |
| Tallinn | Medendi | Home nursing | To increase the engagement of the older person, informal caregiver and different professionals in the development of a joint care plan, and to support information exchange between the older person, informal caregivers and professionals about the older person’s situation, needs and objectives. | |
| Germany | Uckermark | KV RegioMed Zentrum Templin | Rehabilitative care | To enable people with care needs (including people who completed a complex therapy program) to receive the right services, by providing information and advice on available care and support services. |
| Berlin Marzahn-Hellersdorf | Careworks Berlin | Home nursing and rehabilitative care | To improve inter-professional case management and multidisciplinary collaboration between general practitioners, (para)medical therapists and nurses by transferring prescription-competence from General Practitioners to (para)medical therapists and nurses; and to establish formalised interactions and communication space among involved (formal and informal) caregivers. | |
| Norway | Surnadal | Surnadal Holistic Patient Care at Home | Home nursing and rehabilitative care | To expand and improve healthcare services delivered at home. |
| Søndre Nordstrand in Oslo | Søndre Nordstrand Everyday Mastery Team | Rehabilitative care | To increase people’s sense of personal control, reduce reliance on traditional care services and maintain and encourage good functional ability and social participation among older people. | |
| Spain (Catalonia) | Osona | Severe Chronic Patients/Advanced chronic disease/Geriatrics Osona | Proactive primary and intermediate care | To improve person-centeredness of care by conducting a standard, multidimensional joint assessment and elaborating a shared individualised care plan among involved health care and social care professionals and the older people and informal caregivers. |
| Sabadell | Social and health care integration Sabadell | Proactive primary care | To establish a systematic, multidimensional assessment and care plan tailored to multiple health and social care needs of each older person and to establish care plans that people feel knowledgeable and active about, targeted at those unknown to social services. | |
| The Netherlands | West-Friesland | Health and social care West-Friesland | Proactive primary care | To improve collaboration between General Practitioners and practice nurses, case managers for people with dementia and the social community team in order for them to adequately address older people’s health and social care needs; and to improve professionals’ person-centred way of working. |
| Arnhem | Good in one Go | Transitional care | To clarify and align the various scenarios of a sudden need for more intensive care of a person living at home in a crisis (such as dementia or brain injury). | |
| United Kingdom | Kent | Over 75 Service | Proactive primary care | To keep older people with long-term conditions and complex care needs at home independently for as long as possible and to improve care coordination across existing services around these people. |
| Kent | Swale Home First | Transitional care | To ensure medically optimised hospitalised people are able to be discharged straight home with the right support and to make the person’s discharge smoother, quicker and safer by moving to a single assessment. |
Table 2
Analysis framework used for content analysis of data sources.
| Main codes | Sub-codes |
|---|---|
| Identifying and managing risks* | Activities Experiences from older people and their informal caregivers Experiences from health and social care professionals and managers |
| Addressing risks deriving from older people’s functioning | Activities Experiences from older people and their informal caregivers Experiences from health and social care professionals and managers |
| Addressing risks deriving from older people’s behaviour | Activities Experiences from older people and their informal caregivers Experiences from health and social care professionals and managers |
| Addressing risks deriving from older people’s social environment | Activities Experiences from older people and their informal caregivers Experiences from health and social care professionals and managers |
| Addressing risks deriving from older people’s physical environment | Activities Experiences from older people and their informal caregivers Experiences from health and social care professionals and managers |
| Addressing risks deriving from older people’s health and social care management | Activities Experiences from older people and their informal caregivers Experiences from health and social care professionals and managers |
| General experiences with safety for older people living at home | Experiences from older people and their informal caregivers Experiences from health and social care professionals and managers |
[i] * This theme was identified inductively after reviewing the data.
Figure 2
Activities addressing safety risks as identified in the participating integrated care sites.