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International Innovation


Care Chain Frail Elderly (CCFE)


This nurse-led intervention provides case management and coordinates health and social services for very frail elderly adults. Program participants may have complex conditions marked by multiple comorbidities, or they may need social supports to address functional or informal care needs. Participants are visited at home by a nurse practitioner, who carries out a holistic assessment of health care problems, care needs, and personal goals. Individualized care plans, finalized at meetings of the multidisciplinary care team (which includes the patient and caregiver), focus on advanced care planning, polypharmacy, transitions in care, and development of a network of community providers and services. Case management addresses complex health needs and case management of community-based social care.


A pilot launched in 2011 in one region was scaled up to include more regions in 2013. The funder evaluated the program, and it is being evaluated as part of SELFIE (Sustainable Integrated Care Models for Multi-morbidity: Delivery, Financing and Performance), a Horizon2020 EU project using standardized metrics, quasi-experimental comparisons to control populations, and a common research methodology (multicriteria decision analysis).


For providers. Providers refer patients to the care team, many of them through primary care practices. General practitioners (GPs) still play an important role, but the program focuses on the multidisciplinary team. The nurse practitioner, who is key to patient assessment, also coordinates health care and community-based social care. Care planning has a clear focus on patient goals and integrated care.    

For patients/caregivers. Patients are recruited through a comprehensive assessment conducted in the homes. Patients and their caregivers help develop the individualized care plan and are active in meetings of the care team. The program provides support for enrollees and their caregivers in the community.   


CCFE is a collaboration of two health insurers and three care groups that piloted an innovative bundled-payment model for frail elder care that covers all primary care costs. The care groups employ GPs and nurse practitioners, who implement the approach in their daily practices. Health insurers are important stakeholders in the development and continuation of CCFE. The community network is central to the care process, especially the integration of health and social care.


Two major health insurers are involved in CCFE’s financing. Under the bundled payment scheme — the dominant financing model — participants have no change in their out-of-pocket costs for the same services. One of the insurers is conducting an evaluation to inform the future direction of the bundled payment system.


Contact: [email protected]

Additional background:

Additional information on impact: A summary of the research design and methods for the SELFIE evaluation is available at

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