Partnerships for sustainable development of integrated care

IntroductionIn order to provide health and the best care to everyone, now and in the future, continuity of health for citizens and integrated care around the patient, within a regional network of care and welfare, is necessary. The aging population and the increasing demand for care, the availability of new treatments, the growing staff shortage and the changing role of the citizen maintaining one's own health make it clear that we need a paradigm shift in organizing the care for health.Description of policy context and objectiveRegional hospitals in the Netherlands have jointly launched their new strategic course ""from hospital to health organization"". In addition to (medical) treatment, this strategy also focuses on prevention, reduction of ill health and promotion of health; strongly anchored in the region and together with the patient. It is essential here to take into account the social determinants of health, which requires to involve new partners in this endeavor.Targeted population28 regional hospitals are spread throughout the Netherlands and serve about 30 percent of the Dutch population.Highlights (innovation, Impact and outcomes)One of these hospitals 'Rivierenland' has installed for this purpose a special “e-novation” committee. This committee carries out various projects aimed at integrated care and regulates all changes in the field of data sharing, remote digital care, and involving with patients and external partners in pursuing the new vision. Important first steps have been made by the cooperation of primary care providers and the Rivierenland in providing diagnostic services. In the Connect program the hospital provides a backbone for the region to provide these services.Another example is the approach to prevent citizens to develop chronic diseases, which is based on the national initiative of the associations for chronic diseases, like diabetes, COPD and heart failure. For each of these conditions prevention programs have been developed based on (multi)disciplinary guidelines in the care standards. The three care standards have been integrated in one integrated care program, which has two focal points. The first is focused on maintaining health by preventing citizens at risk of getting a chronic disease, the second is to manage the chronic diseases of the patient and prevent complications. This will give a boost to the continuity of health approach.Comments on TransferabilityThis approach focusing on both maintaining health and prov