Urban Health Centres Europe
Development of the UHCE template
Toon Voorham, Elin Koppelaar, Rens Martijn (University of Applied Science Rotterdam)
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In the project Urban Health Centres in Europe the aim is to integrate health and social care for the frail elderly. Health professionals provide standardized preventive care, and monitor and facilitate integrated care pathways. The nurses/assistants pro-actively assess frailty in the houses of the patients, while observing (self) medication and fall risks. Together with the patient (and relatives) the physician aims for a shared decision on an integrated (social and health) care pathway. The different pathways include the management of polypharmacy, the prevention of falls and the dealing with loneliness among elderly. In WP4 the general template of the different pathways was developed (See graph), based on literature search for the evidence base of the interventions, and a series of focus group interviews with the elderly, their informal care givers, the health professionals and the policy makers in every town in the project.
A big challenge in the UHCE project was to develop interventions in five different health and social systems. Therefore, the formulation of the pathways was ‘to be as general as possible, and as specific as inevitable’. In relation to the prevention of falls by the elderly the evidence base was very specific. We could describe the most effective elements of the prevention of falls. Also for the polypharmacy there were different programs available, with supporting evidence. The pathway for dealing with loneliness was the least specific, and there was little evidence.
So, the local project leaders were asked to translate the template into practical activities for the elderly and their care givers, making use of the possibilities in their own city. In the evaluation of the project we will know whether these practical activities could generate the effects we hope for.
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