Table 1.

Characteristics of thirteen integrated care sites participating in the SUSTAIN project (adapted from de Bruin et al., 2018 [7] and de Bruin et al., 2018 [28]).

Country	Region	Integrated care site	Type of care services	Improvement project objective
Austria	Vienna	Gerontopsychiatric Centre	Dementia care	To improve detection of dementia and case- and discharge management of hospitalised people identified with a cognitive disorder.
Estonia	Ida-Viru	Alutaguse Care Centre	Home nursing and rehabilitative care	To develop a person-centred way of working by engaging older people, informal caregivers and a multidisciplinary care team in the process of defining a goal-directed care plan.
	Tallinn	Medendi	Home nursing	To increase the engagement of the older person, informal caregiver and different professionals in the development of a joint care plan, and to support information exchange between the older person, informal caregivers and professionals about the older person’s situation, needs and objectives.
Germany	Uckermark	KV RegioMed Zentrum Templin	Rehabilitative care	To enable people with care needs (including people who completed a complex therapy program) to receive the right services, by providing information and advice on available care and support services.
	Berlin Marzahn-Hellersdorf	Careworks Berlin	Home nursing and rehabilitative care	To improve inter-professional case management and multidisciplinary collaboration between general practitioners, (para)medical therapists and nurses by transferring prescription-competence from General Practitioners to (para)medical therapists and nurses; and to establish formalised interactions and communication space among involved (formal and informal) caregivers.
Norway	Surnadal	Surnadal Holistic Patient Care at Home	Home nursing and rehabilitative care	To expand and improve healthcare services delivered at home.
	Søndre Nordstrand in Oslo	Søndre Nordstrand Everyday Mastery Team	Rehabilitative care	To increase people’s sense of personal control, reduce reliance on traditional care services and maintain and encourage good functional ability and social participation among older people.
Spain (Catalonia)	Osona	Severe Chronic Patients/Advanced chronic disease/Geriatrics Osona	Proactive primary and intermediate care	To improve person-centeredness of care by conducting a standard, multidimensional joint assessment and elaborating a shared individualised care plan among involved health care and social care professionals and the older people and informal caregivers.
	Sabadell	Social and health care integration Sabadell	Proactive primary care	To establish a systematic, multidimensional assessment and care plan tailored to multiple health and social care needs of each older person and to establish care plans that people feel knowledgeable and active about, targeted at those unknown to social services.
The Netherlands	West-Friesland	Health and social care West-Friesland	Proactive primary care	To improve collaboration between General Practitioners and practice nurses, case managers for people with dementia and the social community team in order for them to adequately address older people’s health and social care needs; and to improve professionals’ person-centred way of working.
	Arnhem	Good in one Go	Transitional care	To clarify and align the various scenarios of a sudden need for more intensive care of a person living at home in a crisis (such as dementia or brain injury).
United Kingdom	Kent	Over 75 Service	Proactive primary care	To keep older people with long-term conditions and complex care needs at home independently for as long as possible and to improve care coordination across existing services around these people.
	Kent	Swale Home First	Transitional care	To ensure medically optimised hospitalised people are able to be discharged straight home with the right support and to make the person’s discharge smoother, quicker and safer by moving to a single assessment.