Tip 8: ‘Make use of proven care models such as the chronic care model.’

Install a multidisciplinary team of professionals, led by the GP, around the needs of elderly living at home, based on frailty level to decrease complexity of care needs, increase wellbeing and potentially reduce overall healthcare costs.



The early results of the program show reduction of healthcare problems and high satisfaction among participants. Taking a long-term perspective, the overall outcomes for older adults in terms of quality of care, care consumption and costs are positive. Older adults that receive support from an elderly care team appear to benefit from such an approach. A published business case indicates the potential to reduce annual healthcare costs per older adult by up to 274 euros. However, the cost-effectiveness of the program has yet to be demonstrated and is currently hindered by fragmentation of funding sources and a focus on delivering short-term results.


Transfer to other settings:
  • Although most people may believe the program can reduce long term care needs, increase participants safety and lead to improved quality of live, it is also important to show cost reductions. The evaluation period of 1 year was too short to demonstrate financial reductions.
  • One challenge is to find sustainable payment system for integrated care. In the Netherlands the payments for care are fragmented. The current financial system is not appropriate and it will be necessary to get all payers and providers to agree a new model.
  • Capitation and fee for service do not support the scaling-up of integrated care programs. More appropriate is a lump sum payment.


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