Living Lab Better Together in Amsterdam North

In the northern district of Amsterdam a relatively large part of the population is of low social status. This group often has to deal with numerous health care professionals and social or municipal workers simultaneously. As a consequence, many clients receive too much and unnecessary health care and social support with insufficient or even counterproductive results. Therefore, the aim of the BSiN alliance (10 providers of health care, home care and welfare, Achmea Health, TNO) is to develop and evaluate an action program focused on the implementation of integrated care and services from the sectors cure, care and community. The program is developed for people with complex and/or multiple problems and limited self-sufficiency in the northern district of Amsterdam.

The main objective of this study is to evaluate the change in level of participation of the target population after the BSiN intervention, as compared to a control group, by means of improved self-sufficiency on eleven domains of life. Secondary objectives are to evaluate the change in health, in life style and in costs of health care.

The design is an observational study with three evaluation steps: 1) effect study, 2) cost-effectiveness study and 3) process evaluation.

Applying triage and case management for people with multiple complex problems in the Northern district of Amsterdam will improve their level of participation, their self-sufficiency and their health, and result in reduction of health care costs.

Measurements (standardized questionnaire and SSM-D) at baseline (T0), 6 months (T1) and 12 months (T2).

The BSiN intervention is an approach where health care and social services are integrated to provide the best quality care with one coordinating case manager. People that are referred to the BSiN intervention will be discussed in a triage team and assigned to 1 of the 4 quadrants of the Frieslab model (1 = self-support, 2 = client support, 3 = care coordination, 4 = case management). Only people with multiple and complex problems will be assigned to a case manager (quadrant 4). The case manager has two main tasks:

- Stimulate self-sufficiency (empowerment / self-management) (key words: shared decision making, life action plan, motivational interviewing, needs driven).

- Coordinate health and social care (key words: prioritize, contact with all care providers involved, 1 client = 1 coordinator = 1 plan).

The case manager can call in any regular health care provider and social service if needed, in line with the life action plan(which was developed in collaboration with the client).