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Embrace ('SamenOud' in English)


Embrace is a Integrated Elderly Care Program: it is a redesign of the care delivery system into personalized, coherent, proactive and preventive care and support for elderly people of 75 years and older. It is one of the NPO transition-experiments.

Embrace is based on the Chronic Care Model and consists of four interacting key-elements which are embedded in the community and health care system. Embrace is located in the GP-practice: close by the elderly people living at home or in a ‘home for the elderly’. All patients (75+) belonging to this practice are eligible for Embrace care.

3 Profiles

Patients receive a questionnaire each year to screen their health situation for complex care needs and frailty. Data are used for triage of these patients to a suitable level of care. Embrace recognizes three levels of care intensity, resulting in three main profiles.  In each general practice an Elderly Care Team (ECT) organizes coherent, suitable, proactive and preventive care for each individual patient. The GP is in charge of this team, which furthermore comprises a district nurse and a social worker (both in the role of casemanager), and an Elderly Care Physician (ECP). The ECTs are supported by a local network of medical and non-medical professionals and volunteers.

A movie about Embrace

(with English subtitles)


About Embrace

As part of a series of case studies on best practices in elder care, Sofia Widén, Program Manager of ACCESS Health Sweden, visited the University Medical Center at the University of Groningen, the Netherlands in September 2015. At the University of Groningen, Sofia interviewed Dr. Erik Buskens and Dr. Klaske Wynia. They discussed the recent National Care for the Elderly Program introduced by the Dutch government.

The full interview is to be read here.


  1. 'Embrace, a model for integrated elderly care: study protocol of a randomized controlled trial on the effectiveness regarding patient outcomes, service use, costs, and quality of care' - BMC Geriatrics
  2. Publication from European Commission about Embrace as Good practice.
  3. Embrace, a model for integrated elderly care. International Journal of Integrated Care, October 2014.
  4. The Geriatric ICF Core Set reflecting health-related problems in community-living older adults aged 75 years and older without dementia: development and validation. Disability and Rehabilitation, March 2015.
  5. Development and psychometric evaluation of a measure to evaluate the quality of integrated care: the Patient Assessment of Integrated Elderly Care. Health Expectations, June 2015 (accepted).
  6. Experiences of community-living older adults receiving integrated care based on the Chronic Care Model: a qualitative study. PLOS ONE, October 2015.

Inschrijven voor de digitale nieuwsbrief


BeterOud heeft de opdracht om succesvolle projecten uit het Nationaal Programma Ouderenzorg (NPO), waaronder SamenOud, verder over het voetlicht te brengen en uit te rollen. Kijk voor meer informatie op de website van BeterOud.

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