P3 - Care Innovation: a coordinated and comprehensive care package

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P3 - Care Innovation: a coordinated and comprehensive care package

Ghent, Belgium
Project Stage:
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

Offer a wide range of care services to older people in great need of care 24/7, with coordination by a case manager / care coach.

About Project

Problem: What problem is this project trying to address?

The introduction of an innovative range of care services (including night rounds, professional alert responses, emergency relief, individually scheduled day care, occupational therapist advice) aims to enable older people (aged 60 or older) to benefit from care in their own home for a longer time. A better harmonization of care services will guarantee the continuity of care for individuals in need of complex and/or long-term care. Intensive counselling of patients/clients by care coaches/case managers as well as optimum cooperation between all partners in charge of both care and carer support, should make it possible to postpone or avoid admission to nursing homes. If individuals/older people in need of care can benefit from quality care in the safe environment of their own home, this will keep health care expenses in check.

Solution: What is the proposed solution? Please be specific!

This is an innovative project because a whole range of services is added to existing initiatives (home nursing, family care…). Unlike for the current offer of services, the care provided in this project is not limited to office hours (8AM-5PM), but can also be offered to individuals in need of care outside office hours and at the weekend: night rounds by professional carers between 10PM en 6AM, evening rounds by professional carers between 5PM and 10PM, weekend assistance. All services are coordinated by a care coach/case manager acting as a single point of contact. Consequently, individuals in need of care or carers only have to contact the care coach to start, adapt… care services. Care coaches monitor the evolution of patients' care needs from start to finish and make adjustments wherever necessary in consultation with patients, carers, general practitioners and the care and assistance providers involved. For individuals in need of care who cannot find their way in the current offer of care services, their care coach/case manager will be the person to talk to. Together with all care and assistance providers involved, the care coach/case manager will assist patients and carers from their first request for care to the final stage (admission to a nursing home or decease).
Impact: How does it Work

Example: Walk us through a specific example(s) of how this solution makes a difference; include its primary activities.

An older individual in need of care can return home after a long stay in hospital thanks to the necessary support during the day, at night and at the weekend. Carers will be less worried and will decide to postpone admission to a nursing home and take care of their mother/father at home, with the necessary professional support: a home nurse will come by every day for medical care, a professional carer will take care of household chores and assistance with daily meals. At 8PM the evening round professional carer will come in to change individuals in need of care and put them to bed. At 11PM and at 4AM the night round professional carer will stop by to see if everything is all right and to change incontinence products. At the weekend too, individuals in need of care can count on a few hours of assistance so that carers have some time to relax. An occupational therapist has screened the home so that the chance of falling has been seriously reduced. Assistance is fully coordinated by a care coach/case manager. All care and assistance providers involved are kept up to date on possible adjustments of care organisation.

Marketplace: Who else is addressing the problem outlined here? How does the proposed project differ from these approaches?

Other organisations focus on only 1 or 2 services exclusively: only night care services, only care coordination… but do not offer 24/7 care services combined with a care coach for coordination. When allocating resources for the project the National Health Insurance Institute (RIZIV) took account of where projects were located. In Ghent there are a few other projects focusing on a part of care provision, but not on 24/7 support and an extensive range of care services. Taking into account the needs of the individual in need of care and the carer, the care coach/case manager will compose an individual, tailor-made care package. Services and staff from other projects will be involved at the request or in the interest of patients.
About You
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About You
First Name


Last Name

Van Asch

Implementer(s) and cooperation partners

Solidariteit voor het Gezin


Social enterprise (partly economically self-sustained through market products and services, primary mission is to solve a social problem)

Country where main implementer is located

, VOV, Ghent

How long has the main implementer been operating?

More than 5 years

Please provide a short description of the main implementer.

'Solidariteit voor het Gezin' is an independent (non profit) service for welfare and health care that offers a versatile range of services starting from home care, but depending on the needs of its clients, is also committed to organizing and coordinating additional services. Assistance is offered by knowledgeable and motivated staff, starting from a humanist vision and dynamic client centered attitude.

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Cooperation partner

Huisartsenvereniging Gent (Ghent General Practitioners' Association)



How does this cooperation partner support the initiative? What competencies and resources does this partner bring to the initiative?

The General Practitioners' Association's first task is making the project known to general practitioners in Ghent. Moreover, general practitioners will also participate in team consultation meetings for selected patients.

Cooperation partner

UZ Gent (Ghent University Hospital)


Public body

How does this cooperation partner support the initiative? Which competencies and resources does this partner bring to the initiative?

The Ghent University Hospital delivers expertise in care for older people and release management. They are in charge of screening and referral of possible patients. The continuity of care and an optimum reintegration in patients' home environment is ensured together with the care coach.

Cooperation partner

OCMW Destelbergen & Gent (Ghent & Destelbergen Social Service Centres)


Public body

How does this cooperation partner support the initiative? Which competencies and resources does this partner bring to the initiative?

The Ghent & Destelbergen social service centres employ occupational therapists who screen patients' homes and make adaptations in order to prevent patients from falling. Furthermore, they teach patients to use simple tools enabling them to live in their homes longer with a few minor interventions.

Cooperation partner

Liever Thuis LM (mantelzorg)



How does this cooperation partner support the initiative? Which competencies and resources does this partner bring to the initiative?

Liever Thuis LM is a volunteer care association that organizes about 5 information sessions every year on relevant topics for individuals in need of care and carers: subsidies in home care, how to prevent falls … During these sessions both parties meet others who are in similar situations.

Problem and solution
Which of these fields of Active and Healthy Ageing are addressed by your initiative?

Health literacy and patient empowerment, Personalized health management, Integrated care for chronic conditions, Independent living solutions.

If none of the above, answer here:
Please describe if and how your stakeholders (cooperation partners, funders, users, etc.) have been participating in defining the problem and developing the solution.

Our various partners have been active in first-line care for many years. Based on their experience they have a clear view of the problems experienced by older people in need of care and of the gaps in the offer of care services leading to early admission to a nursing home for many older people in need of care. Our partners have been involved in the preparation of the project at different levels: defining the target group, defining and developing care services… Carers were also consulted during the elaboration of the project, because without them home care would be impossible.

Has your solution been tested in trials, experimentations, or pilot projects? If yes, please describe the process and outcome.

No, our care services were not tested in advance since elaborating and testing a tailor-made range of services was part of the National Health Insurance Institute (RIZIV) call for projects.

How long has your solution been in operation?

for 1‐5 years

Please select the relationship between your solution and related solutions currently established in our society. Is your solution…

complementary (your solution is complementing existing solutions and compensating their weaknesses while not intending to substitute them)

What barriers might hinder the success of your initiative? How do you plan to overcome them?

Flemish and federal rules and regulations are not entirely harmonised and make it difficult to optimise care services. The various types of care providers and their professional status are often defined by different regulations, which sometimes prevents flexible employment of these professionals. A concrete example: professional carers subject to Flemish regulations who provide assistance at the weekend cannot be replaced in case of illness… As a result, carers will have to be appealed to. However, some individuals in need of care do not have carers or they are unavailable (they are abroad…), which compromises the continuity of care provision.

Organization and funding
Regularly paid employees




External advisers and experts


Others (please specify)
What are the specific professional backgrounds and competencies your team brings to the initiative?

Our team consists of:
- nurses (verpleegkundigen)
- professional carers (verzorgenden)
- nursing assistants (zorgkundigen)
- carers (mantelzorgers)
- occupational therapists
- social workers
- general practitioners
- geriatricians
- volunteers

who, each from their own training, background and experience contribute to the project objective: keeping older people in need of care at home longer with the necessary support.

Please describe your management or coordination structure in the initiative.

Project progress is monitored by a steering committee consisting of representatives of our various partners. Furthermore, a project report must be submitted to the National Health Insurance Institute (RIZIV) every six months. Within Solidariteit voor het Gezin the project is monitored by an administrative coordinator who is also in charge of contacts with the National Health Insurance Institute (RIZIV). Our care coaches ensure care coordination.

Please provide the total yearly budget in Euro that your initiative spends on implementing the solution.


National public funding


European Union public funding


Economic return from own products/services


Foundations and philanthropy capital


Single donations from private individuals


Donations from private companies


Crowdfunding platforms


Participation fees


Other (please specify)

1,5% (overhead costs of the organisation that are not subsidised through public funding)

Target group, scale and impact
Which target group(s) do you want to reach with your solution?

People aged 60 or older who need complex or long-term care after hospitalization or who suffer from serious health complaints, with an inevitable admission to a nursing home on the short term. The patient needs to meet one of the following conditions: FFA/FFB/FFC Katz-scale, FFB/FFC/FFCd Residential Katz-scale, suffering from dementia, 6 or 6+ on the Edmonton-scale.

We also target carers who need professional support to continue to deal with these challenging tasks and to avoid admission in a residential setting.

Please estimate the number of persons within your target group (users, clients, etc.) that you currently reach directly with your solution.

110 (yearly basis)

In which local/regional/national area(s) is the solution currently implemented?


What is the impact on your target group (users, clients) you want to generate?

Many older people (in need of care) are keen to stay at home, in a familiar environment, for as long as possible. In practice, however, a lot of older people live in their homes in awkward and unsafe circumstances because care services are not adapted to the concrete needs of this target group.
With this project we would like to enable older people in need of care to stay at home longer, in worthy and safe conditions, and to postpone and even avoid admission to a nursing home.

What is the wider impact on society you want to generate?

As our population grows older, society faces an enormous challenge. Health care costs are already a considerable part of the budget that can be spent. To keep health care and the impact of an ageing population payable, it is necessary to introduce innovative forms of care aimed at caring for older people at home longer and at providing residential care to older people who are in great need of care but for whom quality care at home is no longer possible. Since there already is a shortage of residential settings, the introduction of 24/7 support at home can remedy this situation.

What are the impacts on your target group you already achieved?

Since the start of the project, older people in need of care have been able to postpone admission to a residential setting with an average of 240 days. Thanks to different types of care (day and night), they have been able to stay in their homes, which would have been impossible without this project. Support by carers and close monitoring by our care coaches makes older people in need of care feel more supported at home, and their specific care needs are met. If attention is paid to quality and safety as well as affordability, older people could/can stay in their familiar environment longer.

How has the impact of your initiative been assessed?

Experience-based self-assessment (you assessed the impacts based on your experiences with the target group), Self-evaluation (you used qualitative and/or quantitative methods to assess impacts), External evaluation of impacts based on quantitative methods (quantitative measurement of impact indicators).

Public information and strategy
What information on your initiative is publicly available?

Mission and strategy, Organisational structure, Information on team members.

Please indicate webpage or contact for obtaining the respective information.
What are your milestones for further developing, implementing, and establishing your initiative in the next three years? Please describe 1-3 milestones.

We would like to continue to improve the range of care services in this project based on the experience we have acquired in the past three years. Both the input of individuals in need of care and professional care providers is very valuable in this respect.

We intend to submit the modified project for a 4-year prolongation in the same region. Additionally, we will submit the improved project for a second region.