Providing integrated health and social care to vulnerable populations in the community

Abstract

Background: Primary care professionals in deprived neighborhoods often see patients with multiple health and psychosocial problems. Health literacy of these patients is often low and self-management limited, due to the multiplicity of problems and a lacking sense of control. Traditional healthcare approaches seem unable to manage the accumulating physical, mental and social problems of these patients. This results in high healthcare consumption, suboptimal health outcomes, patients with unmet needs and frustrated professionals. For patients with multiple health and psychosocial problems, integrated care from medical and mental health professionals and social services is needed. But many vulnerable patients are not familiar with social services in their neighborhood, and may find it difficult to accept such support. As they often visit the primary care practice, doctors and practice nurses could facilitate access to social care. However, like their patients, they are not always aware of which services are available and the support they can offer. Collaboration of these professionals as a team around patients, and an integrated approach to help patients manage their health and psychosocial problems in relation to each other, could benefit both patients and the healthcare system. This asks for a biopsychosocial vision on health, that goes beyond the dominant medical perspective traditionally hold by primary care professionals. In many countries initiatives are developed to strengthen local integration of medical and mental healthcare and social services. Important issue is the signalling of 'shared clients'. In this workshop we present two initiatives, one from the Netherlands and one from Finland. We will discuss their merits as well as their options, barriers and conditions for structural implementation and transformation to other regions. Aims and Objectives: This workshop aims to learn from experiences of professionals, managers and researchers involved in the development, implementation and evaluation of collaborations of primary care and social care providers targeting vulnerable populations. For this purpose, two initiatives will be presented and discussed: Overvecht Gezond! (Healthy Overvecht), The Netherlands Parempi Arki (Better everyday life), Finland These projects show similarities in their aims, target populations and development methodologies, but differ in their scale, management structure, policy and legal context. Regarding the latter, Finland is currently preparing a national-level reform to integrate its health and social care systems. In the Netherlands, municipalities have become fully responsible for social care. Format: Introduction: scope of the workshop [Mieke Rijken, chair, 5 min] Overvecht Gezond!: description, experiences, observations [Chantal Leemrijse/Petra van Wezel/Nikki Makkes/Neis Bitter, 20 min] Parempi Arki: description, experiences, observations [Anneli Hujala/Erja Oksman/Risto Kuronen,20 min] Interactive discussion (supported by mobile technology) [30 min] Target audience: Care professionals working in (primary) healthcare or social care, managers of care organisations, patient organisations, financers, policy-makers at local, regional and national level Learnings/Take away: Recognizing 'shared clients' is a first step in developing integrated health and social care at local level. 'Sitting at the same table' opens the eyes to see the benefits of multisectoral collaboration. A shared health and social care plan is key for providing person-centred care, and facilitates multiprofessional and multisectoral collaboration.