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Integrated Care for Older Adults: a struggle for sustained implementation


Sander Holterman

University Medical Centre Groningen, NL
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Integrated care has been suggested as a promising solution to disparities in access and sustained high quality long-term care as emerging in Europe’s ageing population. However, a better understanding of context-specific barriers and facilitators for implementation and best practices is needed. We aim to gain this better understanding by examining seven years of Embrace, a Dutch person centred and integrated care programme that provided proactive and preventive care and support for older adults. It  was based on two evidence-based models (Chronic Care Model and Kaiser Permanente Triangle) and ran from 2012 to 2018. We describe the initial goals, the contextual, financial and policy changes which despite successful deployment negatively affected programme continuation.


We used a mixed method instrumental case study design to gain insight into the complexity of sustained implementation of Embrace within the Dutch context. To describe key elements and outcomes, information from journal articles, project reports, intervention protocols and financial agreements was collected and analysed. Semi-structured interviews on the implementation process and sustainability were conducted with programme coordinators.


The majority of health outcomes were positive, and perceived quality of care improved, albeit no clear-cut savings were observed, and costs were not balanced across stakeholders (i.e. providers, health insurer and municipality). The costs of the Embrace intervention and its evaluation primarily came from grants. The costs for health and social services provided were covered by multiple funding schemes. After the national long-term care provision and financing reforms in 2015, crucial elements of the intervention could no longer be funded, such as the screening activities and risk stratification, the Electronic Elderly Record, and the self-management support and prevention programme.


The financial disincentives and fragmented funding did not support the integration of health services and made it impossible for Embrace to achieve sustained implementation.


This seven-year evaluation of Embrace underscores the importance of an enabling context of policy and funding. These prerequisites are crucial to transform at organisational and clinical level from reactive and problem solving into proactive and preventive health services.

Lessons learned.

The right context is crucial for sustained implementation of integrated person-centred health services. Payment models should incentivise the integration of care before the necessary change at organisational and clinical level is possible.


The multiple journal articles and reports used for this evaluation of Embrace focus primarily on  outcomes. An in depth process evaluation would have shown even more how context and outcomes interact.

Future research.

Comparable interventions could benefit from evaluation methods that aim to better understand which mechanism make elements work in which context. Collective case studies using comprehensive frameworks could promote  learning between different health systems.

With a new national framework for integrated person-centred health services for older adults in development, based on the building blocks of Embrace, there still is perspective on revival.

How to Cite: Holterman S. Integrated Care for Older Adults: a struggle for sustained implementation. International Journal of Integrated Care. 2021;21(S1):117. DOI:
Published on 01 Sep 2021.


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