Embrace (“SamenOud” in Dutch) is a population-based integrated care model based on the Chronic Care Model and the Kaiser Permanente Triangle. The essence of Embrace is the integration of the various policies, approaches, and resources present in the care for elderly people. By means of annual screening and triage, elderly people aged 75 years and older are assigned to one of three risk profiles (robust, frail, or complex care needs) with corresponding care and support intensity levels. Next, a multi-disciplinary Elderly Care Team offers appropriate personalized, pro-active, and preventive care and support.
Societies worldwide are challenged by the ongoing growth in health care expenditures and changing patterns in the demand for health care. Long-term care expenditures continue to grow and are expected to double within the coming decades. Furthermore, the number of elderly people with multiple chronic conditions is increasing drastically. More than 50% of people aged 60 years and older suffer from multiple chronic conditions and this percentage will further increase in the coming years. Contemporary health care systems face difficulties in solving these challenges, as they have originally been designed to solve single, acute, and mainly short-term diseases. Associated ongoing specialization and technological improvements have led to fragmentation of care delivery and resulted in a substantial increase in health care expenditures. In addition, structural and financial barriers have further increased the segmentation of organizations that provide primary and secondary care, health care, and social care. Moreover, this fragmentation of care negatively affects the provision of integrated long-term care and support for the chronically ill and for elderly people with complex care needs. Despite the wide array of health services they use, these patients do not always receive appropriate and coherent care. This often leads to adverse drug events, difficulties with participation in treatment, and even treatment errors. Consequently, health care systems need to be transformed. Integrated care models promise to provide a solution to control these health care challenges.
Embrace is an integrated care model based on the Chronic Care Model (CCM) and the Kaiser Permanente (KP) Triangle. The CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community.
The aim of the CCM is to improve quality of care and patient outcomes by linking community services with the health care system. It has four key elements which are all embedded in Embrace: self-management support, delivery system design, decision support, and clinical information systems.
The KP Triangle, a population management model for service delivery, is used to provide a suitable level of care and support intensity. For this purpose, participants are allocated to one of three Embrace risk profiles, based on annual screening and triage: robust (healthy; 64% of the population), frail (risk for complex care needs; 16%) and complex care needs (multimorbidity; 20%). Robust elderly people follow a self-management support program. Frail elderly people and elderly people with complex care needs receive individual support by a multidisciplinary Elderly Care Team, besides following the self-management support program.
A multidisciplinary Elderly Care Team is led by the general practitioner, and further consists of an elderly care physician, a district nurse, and a social worker – the last two acting as case managers. The focus of the Elderly Care Team is on realizing patient-centered, proactive, preventive, and coherent care and support. The case manager navigates the person through the complex processes of organizing appropriate care and support in the most efficient, effective, and acceptable way.
The self-management support program consists of effective self-management support strategies that are systematically applied by the members of the Elderly Care Team, including shared decision making, motivational interviewing, goal attainment, and action planning. Community meetings and activities for participating individuals are organized in which the need for prevention and endorsing a healthy lifestyle as well as maintaining self-management abilities are emphasized.
Decision support is addressed through multiple decision support tools. Examples are the triage instrument, to indicate a suitable level of care and support intensity, and a structured history questionnaire – based on the International Classification of Functioning, Disability and Health – to assess the most common health-related problems of community-living people aged 75 years and older. New decision support instruments are added to the program and incorporated in the Electronic Elderly Record System.
Clinical information from the annual screening and triage is presented in a web-based electronic record system. This system includes personal health records that contain individual triage data, a history questionnaire, and an individual care and support plan with information about goal setting, actions performed, and evaluations.
Embrace was initiated by the Department of Health Sciences of the University Medical Center Groningen, health insurance company Menzis, and health care organization Meander. During the first years (2012-2014) Embrace was funded by governmental funds. The local health insurance company Menzis and participating municipalities Stadskanaal, Veendam, and Pekela intend to find financing for structural embedding of Embrace. In addition, numerous organizations and municipalities have already shown interest in Embrace. At present, Embrace is also being implemented in the province of Drenthe.