Ludo Glimmerveen, Lecturer at the University of Amsterdam, explains how the Dutch organisation Geriant provides an integrated set of care services for people with dementia in the community. Since 2000, Geriant has offered a community-based service to people diagnosed with dementia, 24 hours a day, 7 days a week. The teams include case managers, social geriatricians, psychiatrists, clinical psychologists, dementia consultants, and specialised home care nurses. Case managers act as the focal point for the client and his or her informal caregivers, co-ordinating services from the team and from other network partners including GPs, hospitals, home care and welfare organisations.

1. INTEGRATED COMMUNITY CARE FOR PEOPLE
WITH DEMENTIA IN THE NETHERLANDS
LUDO GLIMMERVEEN - VU UNIVERSITY AMSTERDAM
The King’s Fund Integrated Care Summit
Making integrated care happen at scale and pace
Wednesday, 8 May 2013

2. Faculty of Social Sciences
GERIANT - FOUNDING HISTORY
2
Independent organization (2004)
Joint program (2000)
The King's Fund Integrated Care Summit
Before 2000…

3. Faculty of Social Sciences
GERIANT - CARE MODEL
3
GP referral
• Diagnosis
• Treatment
• Case management
CARE HOME CLIENT DECEASES
SERVICES FOR CLIENTS & INFORMAL CARERS
The King's Fund Integrated Care Summit

4. Faculty of Social Sciences
Social
Geriatrician
Psychiatrist
Clinical
Psychologist
Specialized home
care nurse
GERIANT - CARE MODEL
4
Clinical
case
manager
Case management
&
providing treatment…
…as part of
multidisciplinary team
Short-stay
Clinic
The King's Fund Integrated Care Summit

5. Faculty of Social Sciences
Social
Geriatrician
Psychiatrist
Clinical
Psychologist
Specialized home
care nurse
CARE NETWORK
5
Clinical
case
manager
NETWORK PARTNERS
Home care – Welfare – GP –
Hospital – Nursing Homes
Short-stay
Clinic
The King's Fund Integrated Care Summit

6. Faculty of Social Sciences
Social
Geriatrician
Psychiatrist
Clinical
Psychologist
Specialized home
care nurse
VARIOUS FORMS OF INTEGRATION
6
Clinical
case
manager
NETWORK PARTNERS
Home care – Welfare – GP –
Hospital – Nursing Homes
6-MONTHLY PHONE CALLShort-stay
Clinic
The King's Fund Integrated Care Summit

7. Faculty of Social Sciences
Social
Geriatrician
Psychiatrist
Clinical
Psychologist
Specialized home
care nurse
VARIOUS FORMS OF INTEGRATION
7
Clinical
case
manager
NETWORK PARTNERS
Home care – Welfare – GP –
Hospital – Nursing Homes
MULTIDISCIPLINARY
MEETINGS /
JOINT VISITS
Short-stay
Clinic
The King's Fund Integrated Care Summit

8. Faculty of Social Sciences
Social
Geriatrician
Psychiatrist
Clinical
Psychologist
Specialized home
care nurse
VARIOUS FORMS OF INTEGRATION
8
Clinical
case
manager
NETWORK PARTNERS
Home care – Welfare – GP –
Hospital – Nursing Homes
ARRANGE / INSTRUCT /
ALIGN CARE WITH
NETWORK PARNERS
Short-stay
Clinic
The King's Fund Integrated Care Summit

9. Faculty of Social Sciences
Social
Geriatrician
Psychiatrist
Clinical
Psychologist
Specialized home
care nurse
VARIOUS FORMS OF INTEGRATION
9
Clinical
case
manager
NETWORK PARTNERS
Home care – Welfare – GP –
Hospital – Nursing Homes
INTERORGANIZATIONAL
PLATFORMS FOR
INDIVIDUAL CLIENTS
Short-stay
Clinic
‘DEMENTIA
HOME TEAM’
The King's Fund Integrated Care Summit

10. Faculty of Social Sciences
Social
Geriatrician
Psychiatrist
Clinical
Psychologist
Specialized home
care nurse
VARIOUS FORMS OF INTEGRATION
10
Clinical
case
manager
NETWORK PARTNERS
Home care – Welfare – GP –
Hospital – Nursing Homes
Short-stay
Clinic
The King's Fund Integrated Care Summit

11. Faculty of Social Sciences
ORGANIZATIONAL CONTEXT
11 The King's Fund Integrated Care Summit

12. Faculty of Social Sciences
MEASURING RESULTS
Routine
Outcome
Measuring
12 The King's Fund Integrated Care Summit
Satisfaction
surveys:
+ + +

13. Faculty of Social Sciences
EVIDENCE FOR COST SAVING SUBSTITUTION
13 The King's Fund Integrated Care Summit
102,961euro
54,540euro
REGULAR LTC
REGULAR LTC
+
GERIANT (a.o.)
47% less
• 8 Euro / client / day

14. Faculty of Social Sciences
RECAP MAIN FEATURES
14 The King's Fund Integrated Care Summit
•Various mechanisms of integration can be present…
…acting at various levels in the care model
• Fluid structures for integration follow the client’s condition…
…instead of the client following the structures
• Flat organizational structure and small teams…
... facilitating collaboration and creative search for solutions

15. Faculty of Social Sciences
CORRESPONDENCE
Ludo Glimmerveen
Department of Organization Sciences
l.m.glimmerveen@vu.nl
15 The King's Fund Integrated Care Summit