Pursuing the Triple Aim in Hotspotters: Identification and Integrated Care

During the intervention patients receive proactive, integrated and personalised care. An intake consultation using Positive Health tool, or a similar method, the needs of each patient is assessed. In a multidisciplinary meeting with the GP, mental health care practice nurse, a social worker and the patient, a personalised care plan is made. The personal is executed and a care coordinator maintains proactive contact with the patient. Clinical follow-up will be done via a second multidisciplinary meeting.