The Health Network Tennengau – The first population oriented integrated chronic care programme for persons with multiple chronic conditions in Austria

Abstract

We report of our work on a “thick description” of a population oriented integrated care programme in Austria, the Health Network Tennengau (HNT). The HNT is a bottom-up network comprised of social and health service providers and voluntary organisations in the Tennengau region, which is a rural area in the state of Salzburg. The HNT has its origin in a pilot project for medical home nursing care introduced in 1995 and has since gradually evolved into a comprehensive network, targeting all inhabitants of the Tennengau region. However, the activities are especially geared towards senior citizens with multiple medical and social requirements. Document analysis and interviews conducted during the Horizon 2020 project SELFIE show that the HTN puts the patient at the centre of the care process and aims to facilitate integrated care around the patient, namely to provide information, counselling, coordination and interface management through case and care management and improved communication. The interconnectedness with non-medical service providers is a central concern for all stakeholder of the HNT. Thus, the HNT is at its core not a medical programme, but a network between doctors, hospitals, care facilities and diverse social institutions in the region. The HNT has been successful for more than 20 years due to voluntary work and a culture of respect between all stakeholders. However, the sustainability has always been at risk as despite its success, continuous financing has been hard to secure, resulting in limited compensation for the involved partners, a lack of resources for public relations work, as well as a lack of funding especially at the start of pilot projects. As a consequence, the HNT still relies to a high degree on voluntary work. However, this also constitutes a weakness of the HNT, as it is not easily transferable. In other regions, not only the culture, but also voluntary stakeholders are lacking to build up integrated care without proper payment. Thus, the HNT offers manifold points for development that can only be spread by securing a sustainable financing. However, the fact that the HNT has persevered despite a lot of such adverse factors makes it an interesting case to learn from.