2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
THEME 6
Community or neighborhood context
The world faces great demographic as well as economic challenges that will have significant effects if
not adequately addressed. An orientation toward stimulating ageing policies and practices for physical
and social activities is necessary. Little, however, is known theoretically or empirically about the role of
communities in promoting health behaviors and well-being among people, especially to stimulate active
and healthy ageing of community-dwelling older people. During this theme, we will elaborate on the
role of neighborhoods and communities in promoting well-being of its residents. Most important
theories and conceptual models will be discussed as well as innovative models to support people in the
community through networks of health and social care delivery, community health nurses, and
collaboration with informal neighborhood networks.
__________________________________________________________________________________________________________________
Targets for theme 6:
Students can explain the role of neighbourhoods/communities on health (behaviours) and well-being;
Students can apply different complex models/frameworks that incorporate the role of communities in
improving health (behaviors) and well-being;
Students can explain the shortcomings of traditional (models of) care delivery (such as the Chronic Care
Model);
Students are able to reflect on the components of these models/frameworks and translate them into
practice;
Students can analyze the role of communities in different settings.
Inhoud
Knowledge clips................................................................................................................................................2
1. Part A: Introduction to the importance of neighborhoods or communities..........................................2
2. Part B: Expanded Chronic Care Model..................................................................................................4
3. Part C: The Innovative Care for Chronic Conditions (ICCC) framework..................................................7
4. Part D: WHO framework age-friendly cities........................................................................................11
Lecture 6 (6 okt.).............................................................................................................................................14
1. A neighborhood intervention for health promotion & prevention.........................................................14
2. The Age-friendly cities framework in practice – older Surinamese migrants in Rotterdam.....................17
Workgroup meeting........................................................................................................................................19
Homework assignment...............................................................................................................................19
Case study on Age-friendly cities................................................................................................................23
1
,2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
Knowledge clips
1. Part A: Introduction to the importance of neighborhoods or communities
There is and will be a huge increase in the average age across te world. These images show what will
happen in the next years.
There is and will also be an increase of chronic diseases, which in turn increases multiple complex needs
people will have. This is partly due to the aging populations, but also partly because of the better health
care that prolong lives.
This will probably has the consequence that health and social care costs have to be limited, because we
need to keep the healthcare system financially healthy as well.
So, most western countries adopted an ‘Aging in place’ policy. This basically means that older people keep
living in the community, rather than in residential care settings (like nursing homes). On the one hand this
has to do with financial imperatives/duties. But on the other hand, elderly often demonstrate a strong wish
for aging in place; they would prefer to stay at home.
2
, 2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
In order to enable these elderly to age in place, it is important to gain insight into factors that contribute to
a supportive environment. That a community has special significance for elderly is reflected by the time
they spend in the neighborhood. On average, elderly spend 80% of their daytime at home and they are also
confronted with for example disabilities and smaller social networks, which makes them depended on the
community and their neighbors.
Effective prevention of illness and disability actually moves beyond the use of clinical surfaces. It aims to
include community and intersectoral collaboration. A large proportion of preventive interventions are
conducted outside the clinical setting, and rather in the community itself.
The CCM does not sufficiently include health promotion, and the prevention of diseases and disabilities.
The CCM does include the community in its model. However, for broader health intervention and
population health promotion, the scope of this community dimension is considered to narrow. In addition
to that, there are many factors that influence our health and well-being. The lifestyle behaviors of people
are not only influenced by individual choices, but also by social, cultural and economic factors in the
environment where people live and work. In the CCM the focus is mainly on establishing linkages between
community resources that are relevant for chronic illness care, it does not take into account the complexity
and interplay among all these different factors that influence health and well-being of people.
This is consistent with the general healthcare shift from illness and disability to more community-oriented
services that focus more on the prevention of illness and disability.
_______________________________________________________________________________________
So we need models that account for the community context in striving for a healthy and active population.
Here we will discuss 3 models/frameworks:
I. Expanded Chronic Care Model
II. Innovative Care for Chronic Conditions framework
III. World Health Organization age-friendly cities framework
3
THEME 6
Community or neighborhood context
The world faces great demographic as well as economic challenges that will have significant effects if
not adequately addressed. An orientation toward stimulating ageing policies and practices for physical
and social activities is necessary. Little, however, is known theoretically or empirically about the role of
communities in promoting health behaviors and well-being among people, especially to stimulate active
and healthy ageing of community-dwelling older people. During this theme, we will elaborate on the
role of neighborhoods and communities in promoting well-being of its residents. Most important
theories and conceptual models will be discussed as well as innovative models to support people in the
community through networks of health and social care delivery, community health nurses, and
collaboration with informal neighborhood networks.
__________________________________________________________________________________________________________________
Targets for theme 6:
Students can explain the role of neighbourhoods/communities on health (behaviours) and well-being;
Students can apply different complex models/frameworks that incorporate the role of communities in
improving health (behaviors) and well-being;
Students can explain the shortcomings of traditional (models of) care delivery (such as the Chronic Care
Model);
Students are able to reflect on the components of these models/frameworks and translate them into
practice;
Students can analyze the role of communities in different settings.
Inhoud
Knowledge clips................................................................................................................................................2
1. Part A: Introduction to the importance of neighborhoods or communities..........................................2
2. Part B: Expanded Chronic Care Model..................................................................................................4
3. Part C: The Innovative Care for Chronic Conditions (ICCC) framework..................................................7
4. Part D: WHO framework age-friendly cities........................................................................................11
Lecture 6 (6 okt.).............................................................................................................................................14
1. A neighborhood intervention for health promotion & prevention.........................................................14
2. The Age-friendly cities framework in practice – older Surinamese migrants in Rotterdam.....................17
Workgroup meeting........................................................................................................................................19
Homework assignment...............................................................................................................................19
Case study on Age-friendly cities................................................................................................................23
1
,2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
Knowledge clips
1. Part A: Introduction to the importance of neighborhoods or communities
There is and will be a huge increase in the average age across te world. These images show what will
happen in the next years.
There is and will also be an increase of chronic diseases, which in turn increases multiple complex needs
people will have. This is partly due to the aging populations, but also partly because of the better health
care that prolong lives.
This will probably has the consequence that health and social care costs have to be limited, because we
need to keep the healthcare system financially healthy as well.
So, most western countries adopted an ‘Aging in place’ policy. This basically means that older people keep
living in the community, rather than in residential care settings (like nursing homes). On the one hand this
has to do with financial imperatives/duties. But on the other hand, elderly often demonstrate a strong wish
for aging in place; they would prefer to stay at home.
2
, 2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
In order to enable these elderly to age in place, it is important to gain insight into factors that contribute to
a supportive environment. That a community has special significance for elderly is reflected by the time
they spend in the neighborhood. On average, elderly spend 80% of their daytime at home and they are also
confronted with for example disabilities and smaller social networks, which makes them depended on the
community and their neighbors.
Effective prevention of illness and disability actually moves beyond the use of clinical surfaces. It aims to
include community and intersectoral collaboration. A large proportion of preventive interventions are
conducted outside the clinical setting, and rather in the community itself.
The CCM does not sufficiently include health promotion, and the prevention of diseases and disabilities.
The CCM does include the community in its model. However, for broader health intervention and
population health promotion, the scope of this community dimension is considered to narrow. In addition
to that, there are many factors that influence our health and well-being. The lifestyle behaviors of people
are not only influenced by individual choices, but also by social, cultural and economic factors in the
environment where people live and work. In the CCM the focus is mainly on establishing linkages between
community resources that are relevant for chronic illness care, it does not take into account the complexity
and interplay among all these different factors that influence health and well-being of people.
This is consistent with the general healthcare shift from illness and disability to more community-oriented
services that focus more on the prevention of illness and disability.
_______________________________________________________________________________________
So we need models that account for the community context in striving for a healthy and active population.
Here we will discuss 3 models/frameworks:
I. Expanded Chronic Care Model
II. Innovative Care for Chronic Conditions framework
III. World Health Organization age-friendly cities framework
3
