The Health Network Tennengau – The first population oriented integrated chronic care programme for persons with multiple chronic conditions in Austria

Abstract

We report of our work on a "thick description" of a population oriented integrated care programme in Austria, the Health Network Tennengau (HNT). The HNT is a bottom-up network comprised of social and health service providers and voluntary organisations in the Tennengau region, which is a rural area in the state of Salzburg. The HNT has its origin in a pilot project for medical home nursing care introduced in 1995 and has since gradually evolved into a comprehensive network, targeting all inhabitants of the Tennengau region. However, the activities are especially geared towards senior citizens with multiple medical and social requirements. Document analysis and interviews conducted during the Horizon 2020 project SELFIE show that the HTN puts the patient at the centre of the care process and aims to facilitate integrated care around the patient, namely to provide information, counselling, coordination and interface management through case and care management and improved communication.The interconnectedness with non-medical service providers is a central concern for all stakeholder of the HNT. Thus, the HNT is at its core not a medical programme, but a network between doctors, hospitals, care facilities and diverse social institutions in the region.The HNT has been successful for more than 20 years due to voluntary work and a culture of respect between all stakeholders. However, the sustainability has always been at risk as despite its success, continuous financing has been hard to secure, resulting in limited compensation for the involved partners, a lack of resources for public relations work, as well as a lack of funding especially at the start of pilot projects. As a consequence, the HNT still relies to a high degree on voluntary work. However, this also constitutes a weakness of the HNT, as it is not easily transferable. In other regions, not only the culture, but also voluntary stakeholders are lacking to build up integrated care without proper payment. Thus, the HNT offers manifold points for development that can only be spread by securing a sustainable financing. However, the fact that the HNT has persevered despite a lot of such adverse factors makes it an interesting case to learn from.

Integrated Care as a Model for Interprofessional Disease Management and the Benefits for People Living with HIV/AIDS

“…The Health Network Tennengau is a low-threshold care system between primary care and the hospital, with handover and takeover visits in the inpatient setting, the transmission of doctor’s letters and findings to the general practitioner, a hospice initiative, the dissemination of population health information on weight reduction and dementia, and senior counseling [ 63 ]. In addition, the “Diabetes under control” program for optimized diabetes care exists in Austria specifically for patients with diabetes mellitus [ 64 ].…”

“…The complexity of HIV infection with the specific problems (ART, adherence, disease management, comorbidities, symptoms, side effects, long-term toxicities, lifestyle, obesity, a lack of exercise, nicotine abuse, and alcohol and drug abuse) and implicit experiences and burdens (stigma, discrimination, hopelessness, anxiety, depression, isolation, and loneliness) of PLWH establish the need for integrated care to be a necessary patient-centered approach to treatment [ 72 , 85 , 86 ]. The term integrated care is not uniformly defined and is often used as a synonym for different models of care [ 56 , 63 , 87 ]. The collaborative participation of physicians with health care professionals from other professions represent the pillars of integrated care for PLWH [ 88 ].…”

Die Rollen und Aufgaben der Advanced Practice Nurse (APN) bei der Versorgung von erwachsenen Dialysepatient*innen

“…Czypionka et al betonen, dass eine Anpassung des Pflegesystems notwendig ist, um die Qualität der Versorgung bzw. deren Steigerung in Zukunft langfristig sicherstellen zu können 3 . Es bedarf neuer, innovativer Konzepte für eine adäquate Betreuung, in deren Mittelpunkt der Mensch und dessen individuelle Bedürfnisse stehen.…”

“…Des Weiteren werden Pflegefachkräfte in enger Kooperation mit anderen Berufsgruppen in die Entwicklung und Umsetzung neuer und moderner Modelle der Pflege und Versorgung eingebunden. Der Fokus wird auf die persönlichen Präferenzen sowie die zielorientierte Pflege der chronisch kranken Menschen gelegt 3 .…”

Präferenzen von Patienten, pflegenden Angehörigen, Leistungserbringern, Kostenträgern und politischen Entscheidungsträgern bei der integrierten Versorgung in Deutschland: Ein Discrete Choice Experiment

“…Die wachsende Zahl mehrfach chronisch Kranker (multimorbider Menschen) mit komplexen Problemlagen stellt viele EU-Staaten und deren Gesundheitssysteme, inklusive Deutschland, vor Herausforderungen 1 2 3 4 5 6 7 . Es wird geschätzt, dass etwa 50 Millionen Menschen in Europa von Multimorbidität betroffen sind, also von mindestens zwei gleichzeitig vorliegenden chronischen Erkrankungen 8 9 .…”