Table 2.

General characteristics of projects and programs (projects 1–4).

Initiative	Embrace	Liverpool City Council’s Healthy Homes Programme	New Zealand Healthy Housing Programme (also known as Counties Manukau Health)	Hennepin Health Accountable Care Organization (ACO)
Country	The Netherlands	UK	New Zealand	USA
Objective	To provide comprehensive, patient-centered, proactive, and preventive care, in addition to supporting all older adults within context of community care; To prolong ability of older adults to age in place by meeting their needs by supporting self-management, detecting changes in health status early, and preventing escalation of health- related problems.	To reduce health inequalities caused by poor quality housing conditions and improve access to health and wellbeing related services; To reduce premature deaths, primary care consultations and hospital admissions; To drive up standards in private rental sector while also addressing wider determinants of health through housing issues and other factors from access to services to lifestyles.	To improve tenant access to healthcare services in order to improve health outcomes. To reduce the risk of housing related health issues, such as an extension to the house, a transfer to a larger home, housing design improvements or creation of healthy environments, including insulation and ventilation. To identify social or welfare issues and provide a link to the appropriate social service agencies.	To treat each person holistically through the coordination of medical and social services to improve health outcomes and reduce cost; To increase use of preventive care and reduce preventable hospital admissions and emergency visits in high-risk population it serves.
Intervention period	2012 – present (pilot phase 2012–2013)	2009 – present	2001 – present	2011 – present
Population size	755 community-living adults in three municipalities	40000 properties eligible; 33000 assessments and 25000 referrals done in year one	9736 residents of 3410 homes in 2001–2007	9054
Target population	Older adults living in community stratified into robust, frail and complex care needs risk profiles (profiles correspond to care intensity levels)	Population living in eligible housing (neighbourhoods with high level of deprivation)	Families at high risk of infectious diseases, living in neighbourhoods with high levels of deprivation and high concentrations of public and other low-income housing.	Population is stratified based on risk and high cost; Patients with high risk/cost have highest priority for intervention.
Sectors integrated or otherwise involved	Primary care physicians (15 practices) and local health and community organizations (welfare service, preventive and medical care)	Public health, primary care, community-level care that includes a range of services, e.g., social care agencies, specialized care (mental health), hospitals, etc.	Joint initiative between Housing New Zealand Corporation (provider of government- funded housing) and District Health Boards that includes other tiers of care (primary care, hospitals) and social service agencies via referral	Hennepin County Human Services and Public Health Department; Hennepin County Medical Center, Level I trauma center and medium-size public hospital and safety net medical system; NorthPoint Health and Well- ness Center, and Metropolitan Health Plan
Model of integration and/or theoretical framework	Chronic Care Model elements (self-management, delivery system design, decision support, clinical information system), Kaiser Permanent Triangle	Initiative is rooted into councils’ understanding how quality of housing affects health and wellbeing of their residents	Socio-ecological model	Shared risk model of integrated delivery of medical, behavioral, and social services for an expanded population of Medicaid beneficiaries
Initiative	Spokane and Clark counties Maternal and Child Health Inequities	North West London Integrated Care Pilot	Integrated Social Care and Health Districts in Hartberg	Open Care Centres for the Elderly (KAPI)
Country	USA	UK	Austria	Greece
Objective	To reduce chronic disease in marginalized communities by improving outcomes and opportunities in early life; To transition Maternal and Child Health services from an individual-focused (mother–child dyads/family) home visiting model to a population-focused, place-based model.	To become a “beacon” for delivering integrated care; To significantly improve patient experience; To decrease emergency admissions by 30% and nursing home admissions by 10% for people with diabetes and the frail elderly through better, more proactive and coordinated care; To reduce cost of care for these groups by 24% over next 5 years.	To offer patients in need of care the possibility to stay at home; To improve and guarantee offer of health and social care in a district; To help patients and their families to find suitable care for their needs; To start and develop care programmes for relatives.	To provide older adults with primary medical, pharmaceutical and nursing care, and social and domestic assistance while they remain at their homes.
Intervention period	2008–2010	2013–2017	Established in 1989, the program changed and cooperation with a district hospital was added in 2000	Established in 1979, it changed throughout 1980s–90s and doubled in size in 2000s to support aging at home; (pilot phase 1979–1981)
Population size	NR	38000	941	17000
Target population	Mothers and children, pregnant women	Older adults age 75+ with diabetes	Community-dwelling older adults	Older adults age 65+, community-dwelling
Sectors integrated or otherwise involved	Spokane Regional Health District and Clark County Public Health led pilots and involved a great number of partners among businesses, schools, clinics.	100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age UK and Diabetes UK)	Social support, preventative and primary medical services and hospital care	Social support and preventative and primary medical services
Model of integration and/or theoretical framework	Socio-ecological model Life-course approach	NR	NR	Innovative programmes aiming at socialisation of elderly, keeping them active, fit and healthy and creating awareness in their social environment.
Initiative	Zorgvoorziening Zijloever (Care friendly district)	Integrated services for frail elders (SIPA)	Torbay Integrated Care Pilot	Gesundes Kinzigtal
Country	The Netherlands	Canada	UK	Germany
Objective	To deliver primary medical, pharmaceutical, nursing care, social and domestic assistance to eligible persons with disabilities living in community.	To respond appropriately to needs of older persons with disabilities; To maintain and promote independence of older persons; To optimize use of community-, hospital- and institutional-based resources	To establish integrated health and social care teams within a single organization to better meet the needs of older people.	To establish more efficient and better-organized health care in cooperation with patients, health professionals and health insurers; To provide best practice health care to all patients.
Intervention period	Established in 1990, program undergone changes and expansion to comprehensive services in 2000s	1999–2001	2005 – present	2006 – present
Population size	NR	1230	145000	69000
Target population	Older adults age 65+ eligible on medical grounds for place in residential home.	Older adults age 64+, community-dwelling, with at least moderate disability	Older adults	All residents
Sectors integrated or otherwise involved	Long term care and wellfare services	Two community-based multidisciplinary teams with full clinical responsibility for delivering integrated care through provision of community health and social services and coordination of hospital and long term care.	Primary and secondary care (primary care trust that also took over hospital care and adult social care services, Torbay Council and Torbay Care Trust)	Physicians’ network and health care management company with background in medical sociology and integrated care management.
Model of integration and/or theoretical framework	Concept of ‘care-friendly districts’ supported by national policies.	Integrated Services for Frail Elderly delivering integrated social and health services, acute and long term care, community- based and institutional services.	“Bottom up” approach; departed from the creation of integrated health and social care team established in Brixham in 2004.	Triple Aim approach, chronic care model, innovative model of integration in its combination of logistical re-engineering of care processes, IT integration, public health and prevention measures.
Initiative	Jönköping County Council	Kaiser Permanente (Southern California)	Nuka System of Care
Country	Sweden	USA	USA
Objective	To improve access in the whole system of care; To deliver more care in the community; To prevent acute exacerbations of chronic disease; To increase value for patients by improving treatment, care, systems and processes	To provide high quality, affordable care to members To manage population health	To build a high-performing health system; To improve access to services; To support relationship-based model of care; To promote customer-owners’ pride and self-confidence; To honour Alaska Native culture
Intervention period	1997-present	1980s-present	1998 – present
Population size	340000	3.5 million	65000 plus 10000 people from remote villages
Target population	Residents in geographic area stratified as: children and young people people with mental health conditions people living with drug and alcohol addiction older people	Insured members, communities and KP’s own employees	All residents in geographic area, including registered patients
Sectors integrated or otherwise involved	Public health Primary care Hospital care Social care	Ambulatory, urgent and emergency care inpatient, continuing care, and virtual (for example, phone, e-mail, and Internet) settings	Local primary care Regional community hospital Tertiary care state wide hub
Care model and/or theoretical framework	Chronic Care Model with a strong focus on quality improvement methods	Fully integrated health maintenance organization with a strong focus on health promotion and disease prevention	Modified Patient-Centered Medical Home