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The past decades have been characterised by the growing prevalence of chronic diseases, the rising number of older and often multi-morbid patients, and changes in the definitions of health and illness. Many health systems have endorsed integrated care strategies as a means to approach the above challenges, as they are expected to lead to better outcomes, increased efficiency and improved access for service users. Generally, integrated care strategies include changes to patient-provider relationships, care process designs, communication infrastructures and staffing provisions. Given health professionals' involvement in all aspects of integrated care, it is assumed that workforce and staffing interventions will affect the implementation of integrated care strategies profoundly. It has become clear that patients with complex health and social problems require a mix of providers that can collectively address their needs. This involves two essential steps: First, designing the appropriate staff and skill mix of the group of health professionals providing care to a specific patient population; and second, organising and managing the interaction of this group of health professionals in practice.

Due to improved living conditions and better health care, life expectancy is expanding very rapidly in many countries (Colombo et al., Help wanted? Providing and paying for long-term care, OECD Health Policy Studies, Paris, 2011). Overall, we consider this as a blessing. But this blessing is to some extent ambiguous. Many people also extend their life with years in which they suffer from multiple chronic diseases, such as dementia, disabilities or frailty.In this chapter we will explore avenues to meeting the multiple health challenges for frail older people, in particular people suffering from dementia and multi-morbidity. We will address how integrated care can be organized for these people. We will apply the construct of the socalled Care Standard and build on principles of person centred care and personalized care. Finally, we will discuss how the organisation of integrated care for frail older people suffering from dementia and/or multiple problems may be built up of similar elements. A community approach combined with a whole person’s point of view is also required.

This chapter provides insight in the potential of integrating care through payment reform in the Netherlands. We begin by briefly outlining the main characteristics of the Dutch health care system, which has been transformed into a system of managed competition in the past decade. We focus on health care, because our case study is situated in this setting. We then describe the implementation of the bundled payment for diabetes care as one main example of stimulating nationwide implementation of integrated diabetes care in the Netherlands. This case study is based on our previous work on integrated care and related issues, which we have described in detail elsewhere (de Bakker et al. 2012; de Bruin et al. 2013; Struijs 2013, 2015a, b; Struijs and Baan 2011; Struijs et al. 2010, 2012a, b, 2015a, b; de Jong-van Til et al. 2013; Lemmens et al. 2015; Mohnen et al. 2015).

The development of integrated care initiatives to overcome service delivery fragmentation has become a global concern. Yet, the lack of guidance in their design and delivery has led to a high risk of project failure. Several authors have proposed driving ideas and strategies to foster care integration but a comprehensive conceptual framework building on the evidence and different perspectives of scientific contributions is still needed. The objective of this article is to explain the process of development and validation of a comprehensive framework that could be used either to standardize descriptions of existing care integration initiatives or as a conceptual basis for reflecting on the effective design of new programs or projects. In an initial phase, we used a comprehensive list of 175 items resulting from a literature review in order to identify a 'core set' of relevant framework items. subsequent phases, we validated the newly developed framework. External experts supported the validation phases. The iteration process resulted in a framework of 40 items grouped into seven dimensions: Person-centered care, Clinical integration, Professional integration, Organizational integration, Systemic integration, Functional integration, and Normative integration. The validated framework proved to be understandable and relevant to identify analytical aspects fostering care integration. It could be adapted as a useful tool to inform the design and implementation of new integrated care interventions as well as to generate standardized description of initiatives to perform insightful comparisons.

Objective: As part of the EU-funded Project INTEGRATE, the research sought to develop an evidence-based understanding of the key dimensions and items of integrated care associated with successful implementation across varying country contexts and relevant to different chronic and/or long-term conditions. This paper identifies the core dimensions of integrated care based on a review of previous literature on the topic. Methodology: The research reviewed literature evidence from the peer-reviewed and grey literature. It focused on reviewing research articles that had specifically developed frameworks on integrated care and/or set out key elements for successful implementation. The search initially focused on three main scientific journals and was limited to the period from 2006 to 2016. Then, the research snowballed the references from the selected published studies and engaged leading experts in the field to supplement the identification of relevant literature. Two investigators independently reviewed the selected articles using a standard data collection tool to gather the key elements analyzed in each article. Results: A total of 710 articles were screened by title and abstract. Finally, 18 scientific contributions were selected, including studies from grey literature and experts’ suggestions. The analysis identified 175 items grouped in 12 categories. Conclusions: Most of the key factors reported in the literature derive from studies that developed their frameworks in specific contexts and/or for specific types of conditions. The identification and classification of the elements from this literature review provide a basis to develop a comprehensive framework enabling standardized descriptions and benchmarking of integrated care initiatives carried out in different contexts.

International audience; This chapter on case management starts with a case story about Julia, a person with dementia, and her case manager, John (Sect. 4.1). It shows six innovations which are necessary to introduce case managers. Julia and John live in the year 2025, in a rich western country with a health system that supports integrated care by means of adequate financing and digitalization of care. Section 4.2 introduces a definition of the concept of case management and discusses important terms in it. Then (Sect. 4.3), two specific competences of case managers are discussed: (1) the assessments of care and social needs and (2) empowering interviewing of clients. The chapter continues (Sect. 4.4) with the comparison of the “ideal world” in the case story in 2025 with the real world in 2015 by focusing on case management practices in The Netherlands and France. The chapter ends (Sect. 4.5) by offering theories to support the implementation of the case manager. The chapter emphasises that case managers are not only for clients with dementia but are relevant as an approach to support other people with health, educational and financial problems; clients with developmental delays; patients with severe mental illness; patients with cancer and metastases; and persons with more than one chronic condition. In this chapter, the words clients, patients and persons are used as synonyms occurring in different care contexts.