Norwegian version of this page

Integrated care initiatives for the elderly in Europe

SUSTAIN is a EU project concerned with promoting and improving integrated care for the elderly with multiple health and social care needs who live at home. Norway, with its two coordinated care initiatives in Surnadal and Oslo municipalities, is one of seven European countries participating in the project.


This project is part of the EU project SUSTAIN.

About the project

Norway, like many western countries, has a growing aging population whose health and social care needs are costly for the local and national government. Well-coordinated healthcare programs can help the elderly with chronic conditions smoothly navigate the health and social care system. The programs can also support the elderly to live at home safely, thereby reducing healthcare costs.

Two coordinated care initiatives are part of Norway’s collaborative project with SUSTAIN. The initiative in Surnadal municipality, Holistic Patient Care at Home (HPH), is a general care pathway that assists patients/service users in navigating the health and social care system from the point of discharge from the hospital. The initiative in Søndre Nordstrand borough in Oslo, Everyday Rehabilitation at Home (ERH), promotes sense of mastery and independence in activities of daily living among users.


The objectives of SUSTAIN, including the collaborative work in Norway, is two-fold:

  1. to improve established integrated care initiatives for older people living at home with multiple health and social care needs, ensuring they are patient-centred, prevention-oriented, efficient, and safe; and
  2. to ensure that improvements to the integrated care initiatives are applicable and adaptable to other health systems and regions in Europe


Results based on exploratory case studies indicated that the initiatives in Norway performed well in terms of the quality of the work environments, the healthcare staff’s interactions with and knowledge about users’ needs, and the systematic ways in which the initiatives’ activities are discharged—especially in the case of initiative in Surnadal. The initiatives’ weaknesses included poor involvement of users and carers in goal setting and care planning, lack of safety training (e.g., basic first aid, medications) for users and carers, inadequate respite for carers, poor communication between some sectors (e.g., municipalities and hospitals), and understaffing. Norway’s initiatives are positive and much needed steps towards integrated care. They have promoted collaboration in care delivery. However, both initiatives are yet to emerge as mature well-functioning coordinated care models.


While an increased life expectancy is a positive achievement for our societies, health systems face challenges on both how to increase healthy life years and how to offer quality care and support for those in need. Governments are encouraging ‘ageing in place’ and community-based care, and answer older people’s expectation to live in their home for as long as possible. Integrated care, involving both formal and informal caregivers, is widely acknowledged to be the way forward in care delivery. 

Read more about the SUSTAIN project.


The SUSTAIN project is funded under Horizon 2020 – the Framework Programme for Research and Innovation (2014-2020) from the European Union under grant agreement No. 634144.


SUSTAIN is a collaborative project involving the following institutions and organizations:

  • VU University Medical Centre (VUmc)
  • The Dutch National Institute for Public Health and the Environment (RIVM).
  • Australian Interdisciplinary Platform on Aging (OEPIA)
  • Age Platform Europe
  • Praxis Centre for Policy Studies
  • The Public Health Foundation (Stiftung Gesundheit)
  • European Health Management Association (EHMA)
  • The University of Oslo
  • International Foundation for Integrated Care (IFIC)
  • National Institute for Public Health and the Environment (RIVM)
  • Vilans Center of Expertise for Long-Term care
  • VU University Medical Centre
  • London School of Economics and Political Science
  • University of Kent
  • The Catalan Agency for Health Information, Assessment and Quality (AquAS)

Project start and finish


Published Apr. 6, 2016 2:04 PM - Last modified Jan. 31, 2017 2:17 PM


Project leader Terje P. Hagen


  • Terje P. Hagen
  • Eliva Atieno Ambugo
  • Kathrine Hofgaard Vaage
  • Margrethe Svinvik
  • Gudrun Broback
  • Lillian Aakervik
  • The teams of the Holistic Patient Care at Home initiative in Surnadal municipality in Mid-Norway
  • The teams of the Everyday Rehabilitation at Home initiative in Søndre Nordstrand borough of Oslo municipality
Detailed list of participants