The International Journal of Integrated Care

Introduction Person- and family-centred care is a widely recognized approach for ensuring quality dementia care [1]. Persons living with dementia (PLWD), family/friend caregivers and healthcare providers describe this approach as “promoting a continuation of self and normality” [2]. Caregivers play an integral role including acting as essential sources of intimate knowledge about PLWD [3, 4].

Introduction Countries worldwide struggle to meet the growing and complex care needs of ageing populations [1]. In the Netherlands, healthcare reforms in 2006 and 2015 aimed to support ageing-in-place, resulting in more older adults with frailty living at home [2]. Approximately 17% of adults aged 65+ living at home are considered frail, involving decline in physical, cognitive, social, and psychological domains [3, 4].

Introduction The prevalence of multimorbidity, the coexistence of multiple chronic conditions, is rising worldwide as populations age [1, 2]. Caring for multimorbid individuals is inherently complex, and the involvement of multiple providers further increases this complexity, frequently leading to fragmented care [3, 4, 5]. Care fragmentation compromises quality of care, increases risks of medical errors, and reduces efficiency in already resource-strained systems [6, 7, 8].

Introduction Severe mental illness (SMI) is defined as any mental disorder lasting at least two years, substantially interfering with multiple life domains, including physical and mental wellbeing, social functioning, work, education, housing, and finances [1].

Introduction The world’s demographic composition is undergoing significant transformations, resulting in a growing proportion of elderly and an associated rise in chronic diseases [1]. Altogether, this causes considerable pressure on healthcare systems’ resources and capacity [2]. This demographic shift presents a challenge in organising coherent patient pathways, as the complexity of treatment and care requirements intensifies [3].

Introduction Fragmented care can occur when patients are moving from hospital to home, which can lead to adverse outcomes [1] as well as impacting health care experience [2] and quality of life (QoL) [3].

Introduction Cardiovascular diseases account for about a third of global deaths, with ischemic heart disease (IHD) and atrial fibrillation (AF) among the most prevalent conditions [1, 2]. Studies have identified several barriers to managing IHD and AF, including lack of consensus among physicians on management strategies, difficulties ensuring consistent follow-up care, and poor patient adherence to treatment [3].

Context and Aim Mrs Smith, aged 42, has recently experienced eviction and has spent several months living on the streets. She faces multiple physical health issues, including diabetes and chronic obstructive pulmonary disease, alongside mental health challenges and substance dependence. A research project embedded within her hospital’s integrated care program aims to assess patients’ experiences. Mrs Smith meets the eligibility criteria and has agreed to join the program.

Introduction Integrated care is a globally acknowledged paradigm in healthcare systems [1]. It encompasses two primary dimensions: integration, which aims to coordinate fragmented elements across the healthcare continuum, and service quality, which ensures timely and effective delivery of care to patients [2]. The model’s core objectives include enhancing healthcare efficiency, optimizing patient experience, and improving clinical outcomes [3].

Background The prevalence of prediabetes was found to be higher than previously estimated in the Netherlands, with approximately 21% of males and 15% of females between 40 and 75 years of age having prediabetes [1]. Prediabetes is characterised by elevated blood glucose levels that are not yet high enough to be classified as diabetes [2]. Around 70% of people with prediabetes develop type 2 diabetes within ten years [2, 3].