Person-Centered Care Coordination Next Steps in a Long Journey

Abstract

Citizens of the Netherlands receive excellent care, when they need it, insurance based funded according to the solidarity principle. Maintaining this system is a huge challenge, as we live longer and the demand for care is growing. With an increasing percentage of multi-morbidity in all age groups the need for integrated network organized care is growing at equal pace. Gradually the need to shift focus to prevention is increasingly understood, but a challenging business model is still lacking. The involvement of citizens in maintaining their health requires a focus on managing the social determinants of health. The concept of the holistic problem list and the overarching care plan provides a unique way to combine both health and disease management. Our vision is to bring control to the patient and promote coordination of all active problems across the health and social care network.

Navegação para pacientes submetidos ao transplante de células tronco hematopoiéticas: uma estratégia de cuidado centrado na pessoa

“…Esse plano de cuidados participativo e abrangente requer infraestrutura de Tecnologia de Informação e as ferramentas digitais contribuem para o sucesso da ação. Dessa forma, o paciente está ativo no planejamento do cuidado e essa colaboração é a garantia do sucesso a fim da obtenção de uma saúde melhor (HOFDIJK;CILLESSEN, 2021).…”