Introduction: “De Koepel” is one of twelve federal pilot projects for integrated care, focusing on chronically ill patients. The goal is to achieve integrated care among the entire population in the region where the pilot is based. As this group is more at risk of developing chronic diseases it is important to focus on vulnerabilities. Vulnerable patients is defined in the broadest sense, e.g. people in poverty, with weak health skills, socially isolated people, migrants and refugees. Ostend (one of the cities where the project is been run) has the highest number of people with a non-Belgian nationality (11 %) and is higher than the Flemish average (10%). Unfortunately, these groups are hard to reach. However, it is important that these groups find access to health-care in Belgium, which is what the collaboration with FMDO and “De Koepel” in Ostend aim to achieve. FMDO is an umbrella organization of about 200 self-associations working with people with a migration background.
 Description: FMDO started in 2018 with health ambassadors and the development of an educational game for the prevention of cancer. FMDO and “De Koepel” engaged in 2021 with the purpose of connecting and improving the lives of people in a diverse society and expanding the initial focus group to chronic ill patients.
 The first step of the project was to conduct outreach to understand the current health-care needs of the target groups. Based on the identified needs, “De Koepel” provided training in participatory lessons to the current ambassadors. Finally, the educational game was adapted based on the information gathered during the trainings. 
 In practice, the educational game allows the ambassadors to provide information regarding health care to people belonging to the target group by playing the game together. Furthermore, connecting with the vulnerable groups can either happen in community centers, shops, hospitals, etc. or through the contacts hours that the ambassadors organize to answer personal and practical questions. 
 Target Population: Vulnerable groups like people in poverty, with weak health skills, socially isolated people, migrants and refugees in Ostend. 
 Highlights: A combination of bottom-up and top-down approach is used to educate, improve health literacy and lifestyle within the target group. From the 39 ambassadors in the project, 22 different nationalities are represented. Through the game, every ambassador or participant can expand their network and knowledge and pass it on to their constituency. 
 Conclusion: The concept of ambassadors emulates that the right target group is reached. The ambassadors are key figures in the project and form the bridge between “De Koepel”, FMDO and the target group. Through the educational game, the ambassadors facilitate access to the correct healthcare information and dissemination of information. However, this game is not comprehensive and can be further expanded based on feedback and further requirements. 
 Prospective, the objective is to measure the number of participants and the impact of the education. In addition, the aim is to increase the content of the trainings provided, improve the educational game and the follow-up of the most vulnerable people.