Integrated care in Eindhoven, a challenge for healthcare providers, provider organizations and patients/clients

Purpose: To share experiences by discussing the necessity, the challenges and the used (implementation) strategies on integrated care. Context: Integrated care and chronic care by SGE will be described. SGE delivers with 260 professionals integrated primary healthcare, based on protocols, standards and disease programs for 80,000 people. There is a formalized and structural cooperation with hospitals, their specialists, social services and other organizations. Because half of all the people with chronic illness have multiple conditions, SGE has taken interest in changing the management of diseases, such as heart failure, COPD, diabetes, depression. Deficiencies in current management and the transformation of health care from reactive to proactive are discussed. Approaches, methods and tools used by SGE are focused on. For example: the transition with the Chronic Care Model. This model summarizes the basic elements for improving health care in health systems at the community, organizations , practice and patient levels. Issues like implementation of chronic care programs and how SGE cooperates with the Maastricht University for evaluating outcomes of effectiveness of integrated care by SGE come up for discussion. Preliminary conclusion: The multi-problem patients do need a change in health systems. Despite everything already done, there is still a long way to go. Local, national and international collaborations and networks therefore are a must. Discussion: Is the Chronic Care Model the model to make integrated care for frail elderly, patients with chronic care or long term care needs possible? The do's and the dont's in implementing integrated care.