To balance, preserve, and improve independent living for those suffering from medical, functional, and social problems by maximizing the use of available public services.

To build an innovative, community-based model to deal with the problems generated by decentralized systems of care and improve services for older people and their families through a person-centered approach.

The Need:

Older people facing medical, functional, and social problems need multi-faceted assistance. The fragmentation across the various public and social service systems that provide care to older adults make it difficult for the latter and their families to access appropriate services and utilize them to the fullest. As a result, older adults do not receive the best possible care, which erodes their quality of life, places a heavy burden on family members, and puts independent living further out of reach.

Target Audience:

Older adults who live in the community and suffer from multiple health, functional, and social problems


Establishment of specialized care teams within the community, including a social worker from the municipal department of social services and a hospital nurse, to diagnose and build intervention programs for older adults. The implementation phase began in 27 municipalities and local authorities after a six-year pilot program.