Abstract
Background: Populations with chronic conditions or other vulnerabilities are at greater risk of receiving inefficient care due to fragmentation and a lack of structure within the healthcare system, leading to health inequities. Our approach focuses on improving health outcomes for these vulnerable populations by ensuring the right care is delivered at the right time and place, with focus on people’s needs.
Approach: In ‘Caring Leuven’, our integrated care network, we collaborate with various stakeholders from primary and specialised care, and community partners to address barriers to effective care delivery. From the perspective of different stakeholders, we notice that the lack of a recognizable structure in primary care is a clear barrier. Additionally, the multitude of fragmented care programs leads to insufficient reach for the target populations. While many initiatives exist across sectors to improve care, they are often not connected and fail to achieve the desired impact.
To address these challenges, we focus on neighborhood-oriented care that integrates both population-level programs and people centered care. This approach ensures care is tailored to the specific needs of individuals and communities while fostering engagement.. By promoting collaboration we aim to create a more connected healthcare system that improves outcomes for vulnerable groups.
Results: We have structured primary care into smaller interprofessional networks (Integrated Neighborhood Teams), enabling us to implement programs vertically and horizontally across different levels of care. These networks provide a platform to connect initiatives from various sectors and ensure care coordination. INTs are primarily involved in chronic care programs for both somatic and mental health conditions. A key next step is to implement a transmurally coordinated collaboration model to reduce unnecessary emergency contacts for vulnerable elderly. This consists of direct telephone access to specialist geriatric advice and the use of urgent slots in the geriatric day hospital to prevent unnecessary emergency contacts. An initial cautious analysis shows us that through this pre-emergency triage, a substantial number of emergency referrals can be avoided and reduced to a planned evaluation at the day hospital. For a smaller but not unimportant part, remote advice is already sufficient, for another part the coordinated decision for emergency admission is still made.
All this will be part of a broader multi stakeholder program for vulnerable elderly or the population with higher risk of becoming frail .
A key focus within the INTs therefore is proactive, low-threshold care coordination, ensuring that patients receive timely and tailored interventions. The neighborhood-based model allows local actors to respond flexibly and quickly to emerging needs. This approach ensures that care coordination is provided at an early stage, maintaining a balance between professional support and the person's self-management.
Implications: Through our collaboration model, we are able to connect previously isolated initiatives and achieve a broader horizontal implementation of programs. This leads to more efficient care processes, applied in the appropriate environments, and enhances the organization of care delivery. By focusing on connection and care coordination, we aim to create a more integrated, effective healthcare system.