Friday 23 May 2025 | 10:45-11:45

Format: Workshop

Stream: Populations

Content filters: n/a

PART ONE: The approach of an integrated care organisation where the right care in the right place is the basic principle

An integrated care organisation offers substantial benefits by combining hospital care, rehabilitation care, elderly care and home care. Through active collaboration between cure and care services, including white-label beds, a GEM team, and primary care cooperation between GPs and geriatricians, we ensure the right care is delivered in the right place. This approach allows us to identify the needs and preferences of our residents early on, leading to Advanced Care Planning and preventing unnecessary hospital admissions. Our goal is to strengthen the care system around each individual and manage the increasing demand for healthcare efficiently. This integrated model enhances patient outcomes, optimises resource use, and ultimately creates a more responsive and sustainable healthcare environment.

In this session, participants will be able to:

• Set up proactive partnerships between organisations


• Create initiatives to provide the right care in the right place


• Provide insight into (care) needs at an early stage, so that unnecessary care is not provided

Carolien Wijsman Saxenburgh; Netherlands

Marga Hoogendoorn Saxenburgh: Netherlands

 

PART TWO: When the going gets tough: From insights to actual changes in a population at risk of major leg amputation

Based on the findings from a cross-sectoral analysis on the trajectory of 80 patients with prior major leg amputation, the Region of Zealand has led a multidisciplinary and cross-sectoral project to optimise the care for the population of citizens with arteriosclerosis and foot ulcers to reduce their risk of major leg amputation. In this session, we will demonstrate how the Region of Zealand organised and facilitated the interdependent improvement efforts across healthcare units and sectors to achieve a common goal. We will give examples of how we co-created and designed the four work packages: Standardising measurements of peripheral blood pressure Increasing use of a cross-sectoral communication tool for citizens with foot ulcers Increasing the use of multidisciplinary teams Improving approaches to shared decision making Also, we will show how we followed up on the improvement results and describe how we went from project to implementation phase. Finally, we will discuss some of the barriers to succeed.

In this session, participants will understand:

• The elements of a multidisciplinary and cross-sectoral project organisation ensuring progress and coordination


• How the content of the work packages was co-designed by carers across hospital units and healthcare sectors


• The implementation and communication plan of the project

Louise Katrine Kjær Weile Region of Zealand; Denmark

Malene Egsgaard-Toft Region of Zealand; Denmark