The SUSTAIN project: lessons learned from improving integrated care for older people living at home in Europe

Introduction: The cross-European research project SUSTAIN (2015-2019) was initiated to take a step forward in the development of integrated care for older people living at home. During the project, SUSTAIN research partners collaborated with local stakeholders from integrated care initiatives to design, implement and evaluate actions and activities to improve current practice, in terms of person-centredness, prevention-orientation, safety, efficiency and coordination. The comparison and integration of findings from these evaluations were expected to increase understanding of what works and with what outcomes when making improvements to integrated care.


Introduction:
The cross-European research project SUSTAIN (2015SUSTAIN ( -2019 was initiated to take a step forward in the development of integrated care for older people living at home. During the project, SUSTAIN research partners collaborated with local stakeholders from integrated care initiatives to design, implement and evaluate actions and activities to improve current practice, in terms of person-centredness, prevention-orientation, safety, efficiency and coordination. The comparison and integration of findings from these evaluations were expected to increase understanding of what works and with what outcomes when making improvements to integrated care. Methods: Thirteen established integrated care initiatives (sites) in seven European countries were studied, using a multiple embedded case study design. In all initiatives, qualitative and quantitative data were collected from multiple sources and analyzed using standardized procedures and tools to ensure uniformity of approach. After conducting site-specific analysis, an overarching analysis was performed, in which findings from the site-specific evaluations were compared and integrated to identify general lessons learned.

Results:
The objectives of the integrated care improvements of the different sites could be divided into two groups: (i) improving or expanding collaboration, communication and coordination between organizations and professionals (not yet) involved in the site; (ii) improving the actual care delivery process, for instance by making care delivery more person-centred. The extent to which integrated care improvements lead to a more person-centred, prevention-orientated, safe, efficient and coordinated way of working differed between sites and types of stakeholders. Professionals involved in implementing the improvements were often positive about outcomes of the improvements, while in some sites, a number of users and carers did not notice much of the changes that were implemented. Furthermore, similar facilitators for the implementation of improvements were identified across the sites, on different levels of the health and social care system, such as strong leadership, and shared and realistic goals. Also challenges towards implementation of improvements were identical among the sites, including factors such as lack of ownership, uncertainties about funding, high staff turnover and incompatible shared IT systems.

Discussion, conclusions and lessons learned:
Across sites, several actions and activities had been implemented to improve person-centred, prevention-orientated, safe, efficient and coordinated care delivery. Many actions appeared to achieve some success, particularly according to professionals. Among users, however, there were mixed views on the improvements. While initiatives had been able to improve their current practices, they also encountered several challenges towards delivering and improving integrated care. A supportive context on different levels of the health and social care system is required for achieving sustainable integrated care improvements.

Limitations:
Where improving care is a challenge in itself, on top of that integrated care intiatives were required to implement improvements in a limited time span and often without additional resources, which may have influenced outcomes. A long-term approach and sufficient resources are recommended for achieving successful and sustainable integrated care improvements.
Suggestions for further research: Sites participating in the SUSTAIN project experienced similar challenges in delivering and improving integrated care. Further research on how these barriers can be overcome is needed.
Keywords: complex intervention research; european research; implementation science; mixed methods