Person-Centered Care Coordination Next Steps in a Long Journey

Area of Science:

• Public Health
• Healthcare Management
• Health Services Research

Background:

• The Dutch healthcare system, funded by insurance and based on solidarity, faces sustainability challenges due to an aging population and increasing care demands.
• Rising multi-morbidity across all age groups necessitates a shift towards integrated, network-organized care models.
• There is a growing understanding of the need for prevention, yet a lack of viable business models hinders its implementation.

Purpose of the Study:

• To address the challenges of an aging population and increasing multi-morbidity in the Dutch healthcare system.
• To explore innovative approaches for integrating health and social care services.
• To promote patient empowerment and enhance the coordination of care across networks.

Main Methods:

• Conceptual framework development focusing on a holistic problem list and overarching care plan.
• Emphasis on managing social determinants of health to support citizen well-being.
• Strategy to shift focus towards prevention within the existing healthcare framework.

Main Results:

• The proposed holistic problem list and overarching care plan offer a unique method for combined health and disease management.
• This approach aims to empower patients by giving them more control over their health.
• Enhanced coordination of all active problems across the health and social care network is envisioned.

Conclusions:

• Integrating health and social care through a holistic, patient-centered approach is crucial for sustainable healthcare.
• Focusing on prevention and managing social determinants of health can improve long-term outcomes.
• Empowering patients and coordinating care networks are key to meeting future healthcare demands.