Coordinating care to older people at home: what works and how can we improve care delivery?

On the 17th April 2019, Nick Goodwin hosted a seminar at the University of Newcastle’s Sydney Campus to examine the international evidence and experience in coordination of care to older people with complex needs in the home environment. Download Nick’s presentation here 

The seminar subject was inspired by the conclusion of a four-year European Union project called SUSTAIN (Sustainable Tailored Integrated Care for Older People in Europe). Working across 13 case initiatives in 7 different EU countries, this project sought to develop support interventions to stimulate integrated care initiatives through an implementation science approach and so contribute to our knowledge on how health and care systems in other countries should seek to design and implement such programmes over time.

IFIC led the work package in the development of a roadmap to guide implementation, improvement, design, engagement of stakeholders, and system-wide transformation as a means to support decision-makers in taking action to better meet the needs of older people whose care today is often so poorly managed and fragmented (see here)

Nick’s seminar outlined a range of evidence-based solutions that have been used to meet the needs of older people that can be summarised as follows:

  • Enhancing service co-ordination and care continuity;
  • Strengthening services provided in the home environment, and in primary and community care settings, to improve access to needed health care services;
  • Developing integrated approaches in the work of care providers and professionals in order to achieve, for example, team-based working between health and social care, across primary and hospital care, or to integrate physical and mental health care;
  • Improving the clinical quality of the patient journey to improve experience and satisfaction, with a specific focus on care transitions from hospital to home; and
  • Working with older people, their families and local communities to strengthen social networks, enable independent living , and focus on an older person’s personal health and wellbeing

But Nick also warned that, in general terms, integrated care strategies today often fell well short of the necessary skills, competencies and capacity to properly deliver care that is truly person-centred and coordinated, in ways that safeguard older people’s dignity, and that empower an interprofessional workforce. Too often, Nick argued, implementation strategies have encouraged structural reorganisations at the expense of innovative care delivery at the clinical and service level where it is needed most. Crucially, few programs have recognised the need to deploy active strategies for change over time that help create an enabling environment for integrated care and overcome the mismatch of motivations of the many stakeholders involved. Whilst not perfect, the SUSTAIN roadmap was a new contribution to support such an understanding and included within its pages many practical tools and approaches that could help in this regard.

The SUSTAIN project was funded under grant agreement 634144 of the EU’s Horizon 2020 Framework Programme for Research and Innovation (2014-2020)

The SUSTAIN Roadmap


Dr Nick Goodwin is the CEO and co-Found of the International Foundation for Integrated Care (IFIC)