integrated community care for people with dementia in the ... · integrated community care for...

INTEGRATED COMMUNITY CARE FOR PEOPLE WITH DEMENTIA IN THE NETHERLANDS

LUDO GLIMMERVEEN - VU UNIVERSITY AMSTERDAM

The King’s Fund Integrated Care Summit Making integrated care happen at scale and pace Wednesday, 8 May 2013

Faculty of Social Sciences

GERIANT - FOUNDING HISTORY

2

Independent organization (2004)

Joint program (2000)

The King's Fund Integrated Care Summit

Before 2000…

Faculty of Social Sciences

GERIANT - CARE MODEL

3

GP referral

• Diagnosis • Treatment • Case management

CARE HOME CLIENT DECEASES

SERVICES FOR CLIENTS & INFORMAL CARERS

The King's Fund Integrated Care Summit

Faculty of Social Sciences

Social Geriatrician

Psychiatrist

Clinical Psychologist

Specialized home care nurse

GERIANT - CARE MODEL

4

Clinical case manager

Case management

&

providing treatment…

…as part of multidisciplinary team

Short-stay Clinic

The King's Fund Integrated Care Summit

Faculty of Social Sciences

Social Geriatrician

Psychiatrist

Clinical Psychologist

Specialized home care nurse

CARE NETWORK

5

Clinical case manager

NETWORK PARTNERS

Home care – Welfare – GP – Hospital – Nursing Homes

Short-stay Clinic

The King's Fund Integrated Care Summit

Faculty of Social Sciences

Social Geriatrician

Psychiatrist

Clinical Psychologist

Specialized home care nurse

VARIOUS FORMS OF INTEGRATION

6

Clinical case manager

NETWORK PARTNERS

Home care – Welfare – GP – Hospital – Nursing Homes

6-MONTHLY PHONE CALL Short-stay Clinic

The King's Fund Integrated Care Summit

Faculty of Social Sciences

Social Geriatrician

Psychiatrist

Clinical Psychologist

Specialized home care nurse

VARIOUS FORMS OF INTEGRATION

7

Clinical case manager

NETWORK PARTNERS

Home care – Welfare – GP – Hospital – Nursing Homes

MULTIDISCIPLINARY MEETINGS / JOINT VISITS

Short-stay Clinic

The King's Fund Integrated Care Summit

Faculty of Social Sciences

Social Geriatrician

Psychiatrist

Clinical Psychologist

Specialized home care nurse

VARIOUS FORMS OF INTEGRATION

8

Clinical case manager

NETWORK PARTNERS

Home care – Welfare – GP – Hospital – Nursing Homes

ARRANGE / INSTRUCT / ALIGN CARE WITH

NETWORK PARNERS

Short-stay Clinic

The King's Fund Integrated Care Summit

Faculty of Social Sciences

Social Geriatrician

Psychiatrist

Clinical Psychologist

Specialized home care nurse

VARIOUS FORMS OF INTEGRATION

9

Clinical case manager

NETWORK PARTNERS

Home care – Welfare – GP – Hospital – Nursing Homes

INTERORGANIZATIONAL PLATFORMS FOR

INDIVIDUAL CLIENTS

Short-stay Clinic

‘DEMENTIA HOME TEAM’

The King's Fund Integrated Care Summit

Faculty of Social Sciences

Social Geriatrician

Psychiatrist

Clinical Psychologist

Specialized home care nurse

VARIOUS FORMS OF INTEGRATION

10

Clinical case manager

NETWORK PARTNERS

Home care – Welfare – GP – Hospital – Nursing Homes

Short-stay Clinic

The King's Fund Integrated Care Summit

Faculty of Social Sciences

ORGANIZATIONAL CONTEXT

11 The King's Fund Integrated Care Summit

Faculty of Social Sciences

MEASURING RESULTS

Routine Outcome Measuring

12 The King's Fund Integrated Care Summit

Satisfaction surveys: + + +

Faculty of Social Sciences

EVIDENCE FOR COST SAVING SUBSTITUTION

13 The King's Fund Integrated Care Summit

102,

961

euro

54,5

40 e

uro

REGULAR LTC

REGULAR LTC +

GERIANT (a.o.)

47% less • 8 Euro / client / day

Faculty of Social Sciences

RECAP MAIN FEATURES

14 The King's Fund Integrated Care Summit

•Various mechanisms of integration can be present… …acting at various levels in the care model • Fluid structures for integration follow the client’s condition… …instead of the client following the structures • Flat organizational structure and small teams… ... facilitating collaboration and creative search for solutions

Faculty of Social Sciences

CORRESPONDENCE

Ludo Glimmerveen Department of Organization Sciences l.m.glimmerveen@vu.nl

15 The King's Fund Integrated Care Summit