SUSTAIN · Project

Ready-Made Roadmap to Reorganize Home Care for Aging Populations Across Europe

healthTestedTRL 5Thin data (2/5)

Imagine your elderly parent needs a doctor, a nurse, a social worker, and home help — but none of them talk to each other. SUSTAIN looked at real care programs across 8 European countries and figured out what actually works to get all those services pulling in the same direction. They built a free online roadmap that shows decision-makers exactly how to set up coordinated home care for people aged 65 and older. Think of it as a tested recipe book for fixing fragmented elderly care, written by teams who tried the improvements themselves and measured what happened.

By the numbers

European countries where integrated care was assessed and improved

partner organizations in the consortium

EUR 5,888,487

EU research investment behind the roadmap

65+

target age group for integrated home care

total project deliverables produced

The business problem

What needed solving

Europe's elderly population is growing fast, but health and social care services remain fragmented — doctors, nurses, and social workers operate in silos, leading to poor outcomes and wasted spending. Organizations trying to coordinate home care for people aged 65 and older lack proven, transferable models for how to actually make integration work across different systems and countries.

The solution

What was built

An open-access online roadmap for planning, designing, and implementing integrated care for older people at home. The project also produced 9 deliverables total, including baseline assessments of existing care initiatives, evaluated improvements across 8 countries, and transferability analyses.

Audience

Who needs this

Healthcare IT companies building care coordination platformsPrivate home care and assisted living providersHealth policy consultancies advising on elderly care reformRegional health authorities planning integrated care programsHealth insurance companies designing elderly care packages

Business applications

Who can put this to work

Healthcare IT & Digital Health

SME

Target: Companies building care coordination platforms or electronic health record systems

If you are a healthcare IT company struggling to design care coordination features that actually get adopted — this project tested integrated care improvements across 8 countries and produced an open-access online roadmap with proven implementation strategies. You can use their findings to build evidence-based features rather than guessing what clinicians and patients need.

Home Care & Assisted Living Services

mid-size

Target: Private home care providers and assisted living operators

If you are a home care provider dealing with uncoordinated services for elderly clients with multiple needs — this project evaluated what makes integrated care work for people aged 65 and older living at home. Their roadmap gives you a tested blueprint to redesign your service delivery, backed by evidence from 13 partner organizations across Europe.

Health Policy Consulting

any

Target: Consulting firms advising governments and health insurers on elderly care reform

If you are a consultancy advising regional health authorities on elderly care reorganization — this project spent 4 years assessing and improving real integrated care initiatives, then packaged the lessons into an actionable online roadmap. Instead of starting from scratch, you can offer clients a EUR 5,888,487 research program's conclusions as the foundation for your recommendations.

Frequently asked

Quick answers

What would it cost to access SUSTAIN's roadmap and findings?

The online roadmap was designed as an open-access resource, meaning it is freely available. The underlying research was funded by EUR 5,888,487 in EU contribution, so the knowledge base behind it is substantial — but the tool itself carries no licensing fee.

Can this scale beyond the 8 countries where it was tested?

A core aim of the project was specifically to ensure improvements are 'applicable and adaptable to other health systems and regions in Europe.' They assessed transferability as a dedicated work strand. However, adaptation to local regulatory and funding contexts would still be needed.

Is there any IP or licensing involved?

Based on available project data, the roadmap is described as open-access. As a publicly funded RIA project, research outputs are generally open. No patents or proprietary licensing are indicated in the deliverable descriptions.

Was this actually tested in real care settings or just theoretical?

Yes — the project conducted baseline assessments of established care initiatives, implemented improvements in co-creation with local teams, and then evaluated the implementation process. This was done across real care settings in 8 countries, not in a lab.

How does this handle different regulatory environments across countries?

The consortium spanned 8 countries (AT, BE, DE, EE, ES, NL, NO, UK) with very different health systems. The project explicitly addressed applicability and adaptability across systems, which means the roadmap accounts for regulatory variation rather than assuming one-size-fits-all.

What concrete tool came out of this project?

The main deliverable is an online roadmap providing policy-makers and decision-makers with an open-access, easy-to-use resource to plan, design, and implement integrated care for older people living at home with complex care needs. A total of 9 deliverables were produced.

Consortium

Who built it

The SUSTAIN consortium of 13 partners across 8 countries (AT, BE, DE, EE, ES, NL, NO, UK) is entirely research and public-sector driven — 3 universities, 6 research organizations, and 4 other entities with 0 industry partners. The 2 SMEs in the group are not industrial companies. This composition is typical for health systems research and means the findings are academically robust but have had no commercial validation. For a business looking to use these results, the gap between research output and commercial product would need to be bridged independently. The coordinator, STICHTING AMSTERDAM UMC in the Netherlands, is a major academic medical center with strong credibility in health services research.

STICHTING AMSTERDAM UMCCoordinator · NL
SIHTASUTUS MOTTEKODA PRAXISparticipant · EE
STICHTING VILANSparticipant · NL
LONDON SCHOOL OF ECONOMICS AND POLITICAL SCIENCEparticipant · UK
OSTERREICHISCHE PLATTFORM FUR INTERDISCIPLINARE ALTERNSFRAGENparticipant · AT
RIJKSINSTITUUT VOOR VOLKSGEZONDHEID EN MILIEUparticipant · NL
EUROPEAN HEALTH MANAGEMENT ASSOCIATIONparticipant · BE
STICHTING INTERNATIONAL FOUNDATION FOR INTEGRATED CAREparticipant · NL
AGENCIA DE QUALITAT I AVALUACIO SANITARIES DE CATALUNYAparticipant · ES
AGE PLATFORM EUROPEparticipant · BE
UNIVERSITY OF KENTparticipant · UK
UNIVERSITETET I OSLOparticipant · NO

How to reach the team

The coordinator is STICHTING AMSTERDAM UMC in the Netherlands. SciTransfer can facilitate an introduction to the research team.

Order a report on this consortium See STICHTING AMSTERDAM UMC profile →

Next steps

Talk to the team behind this work.

Want to apply SUSTAIN's integrated care roadmap to your organization or region? SciTransfer can connect you with the research team and help translate their findings into your specific context.

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