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Supporting integrated elderly care networks in working from a more demand- and person-oriented approach in the Netherlands


Carina Pittens

Vrije Universiteit Amsterdam, NL
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In a Dutch region, various care and welfare organizations that support vulnerable elderly have joined forces in an integrated care network. The network envisions that elderly should continue to live in their own familiar environment as long as possible and desirable, healthy, satisfied and independent. To realize this vision, a demand- and person-oriented approach is necessary. Therefore, the network has introduced an approach based on the concepts of Positive Health and Reablement.

However, an integrated care network implies interprofessional and interorganizational collaboration. Due to the historical anchoring in a fragmented care system, both organizational and financial, this collaboration is not self-evident. Various structural, cultural and process-related barriers should be overcome, to make this network a success. To realize the vision of the network, our research therefore aims to support professionals in the network in working according to this new approach by addressing potential interprofessional and interorganizational barriers.


Over a 9-month period, four multidisciplinary teams in the network received training (4 sessions) in the principles of the new focusing on interprofessional and interorganisational collaboration, and the interaction with the client. The process has been monitored and evaluated – together with all stakeholders – using the validated methodology of Reflexive Monitoring in Action. Reflexive learning was a central aspect, which took shape using a fixed learning cycle: (1) observation, (2) analysis, (3) reflection, and (4) (adaptation of) activities).


Observations revealed that participating professionals were enthusiastic about the new approach. However, they experienced several challenges on organizational, professional and client level. Professionals were uncertain about their skills and competences to bring the new approach into practice. Furthermore, they were unaware and inexperienced how to communicate and collaborate with other professions to provide Positive Health and Reablement to vulnerable elderly. Some were afraid that adopting this new approach touched their professional identity. The training stimulated to become more familiar with the concepts (awareness) and how to bring it into practice (skill development). Not all participants were familiar with each other’s profession and their expertise. The training thereby also helped to get to know each other’s profession – and their expertise – better.


The success of the network requires more than just multidisciplinary collaboration in which care and service professionals work with the same client, but parallel to each other.


A joint vision unifying professionals in a network contributes to realization of integrated care. The training contributed to more awareness and skill development regarding putting concepts of Positive Health and Reablement into practice. However more training is necessary, as the interprofessional and –organizational barriers are still not fully overcome


This project was a success, but should be considered as a niche experiment: it did only include part of the professionals and had a short duration. 


Challenges are experienced and should be addressed on several interrelated domains. To overcome them, reflexive learning is essential.

Future research:

Future research should focus on a continuous learning culture and a more broader implementation in the network, especially for primary healthcare professionals.

How to Cite: Pittens C. Supporting integrated elderly care networks in working from a more demand- and person-oriented approach in the Netherlands. International Journal of Integrated Care. 2021;21(S1):97. DOI:
Published on 01 Sep 2021.


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