Background: After eight years as a federal pilot project for integrated care, Zorgzaam Leuven has established a strong regional foundation uniting partners from healthcare, welfare, academia, and local policy. During the federal pilot (2016–2024), Zorgzaam Leuven implemented community-based, person-centred care models that improved collaboration across sectors. The end of federal funding in 2024 offered both a challenge and an opportunity: how to sustain and expand the collaboration built over nearly a decade?
Approach: To ensure continuity and long-term impact, Zorgzaam Leuven evolved into IFIC Leuven & Beyond, a regional learning and innovation network translating the values and mission of the International Foundation for Integrated Care (IFIC) into local practice. Stakeholders co-created a shared governance model through iterative dialogue and joint priority-setting, defining four strategic action lines:
1. Proactive community-based care through multidisciplinary neighbourhood teams (horizontal integration);
2. Population health management and evidence-based interventions;
3. Integrated care programmes bridging sectors and care levels (horizontal and vertical integration);
4. Knowledge and expertise network development to foster regional, national, and international learning for sustainable system transformation.
Results: This transition illustrates how a local ecosystem can reposition itself from a time-limited pilot to a self-sustaining innovation platform. The process required balancing strong local ownership with meaningful global collaboration, embedding responsible and sustainable innovation principles throughout governance and decision-making.
Becoming part of the IFIC network provided Zorgzaam Leuven with:
• Sustainability and continuity through anchoring within the university KU Leuven and academic legitimacy;
• International visibility and influence as an IFIC-affiliated hub;
• Strategic independence from shifting political agendas;
• Capacity building via co-developed education and training initiatives;
• Access to global learning networks and opportunities to disseminate Flemish/Belgian experiences internationally.
Implications: The transition of Zorgzaam Leuven into IFIC Leuven & Beyond demonstrates how regional ecosystems can evolve from time-limited pilots into sustainable, learning-oriented, and globally connected networks. By integrating IFIC’s framework for person-centered, co-produced, and system-wide care with global principles of responsible innovation, Zorgzaam Leuven positions IFIC Leuven & Beyond as a living lab for equitable, future-oriented, and socially responsible innovation in health.

Background
In this workshop will explore how an entire region can be mobilized toward integrated care, starting from the case of Leuven, Belgium. We will present the lessons learned from the ‘Zorgzaam Leuven’ initiative, which started in 2016 and aims to create and implement stepwise a sustainable, collaborative integrated care model.
Audience
The session is intended for professionals and stakeholders who are interested in implementing integrated care in a region, including primary care providers, policy makers, and organizational leaders. The purpose is to engage participants who seek practical strategies for building long-term partnerships and motivating diverse actors in health and social care to join forces to take steps towards integrated care.
Approach
The workshop will last either 60 or 90 minutes and will be highly interactive, with time dedicated to discussion and group work. The room will be organized in a roundtable format to encourage exchange and discussion.
• Programme Outline (60 minutes):
• Introduction (20 minutes): Presented by Gijs Van Pottelbergh, IFIC Leuven and beyond: Overview of Zorgzaam Leuven: how did we start and how we keep everyone motivated..
• Interactive Group Discussions (20 minutes): Topics include motivating primary care providers, building lasting alliances among partners, and engaging policy makers effectively.
• Conclusions and Perspectives (15 minutes): Presented by [Gijs Van Pottelbergh or colleague]. Future directions: how we continuing as IFIC Leuven and beyond why we need to maintaining independence from government and other structures.
• If 90 minutes: The introduction will include an additional segment on collaboration within neighborhood teams. How this is essential for involving primary care givers
Outcomes
Participants will gain practical insights into mobilizing regional integrated care efforts, strategies for sustaining multi-stakeholder partnerships, and approaches for engaging policy makers. They will leave with inspiration and concrete ideas for applying these lessons in their own contexts.

Background
In the Leuven region, we are witnessing a worrying trend: the number of older adults presenting at the emergency department has increased by 25% overall and by 40% in ambulatory attendances in 4years. Only about 30% of them were referred by a general practitioner. This might illustrate a broader systemic issue. Older adults with chronic or social vulnerabilities face fragmented, poorly coordinated care, causing inefficiencies, preventable hospitalizations, and loss of independence
Within Caring Leuven, our regional integrated care network, we aim to create a proactive, connected model of care. Vulnerable and frail older adults are a key focus group, representing a substantial part of the 5% population subgroup responsible for nearly half of all healthcare spending. By identifying vulnerability early and ensuring coordinated follow-up, we seek to improve quality of life and use resources more efficiently________________________________________
Approach
Our model combines population-based prevention with individualized care coordination, implemented through Integrated Neighborhood Teams (INTs). These small interprofessional networks connect primary care providers, social and community partners. They facilitate coordinated care delivery, ensuring that interventions are timely, person-centered, and aligned with the needs of the neighborhood.
At population level, INTs have started organizing proactive neighborhood screenings, in which older adults can voluntarily participate, to identify early signs of frailty, loneliness, or declining self-sufficiency. They promote healthy living and empowerment through community programs on nutrition, mental wellbeing, and fall prevention, helping older adults remain active and independent
At individual level, team members focus in their own practice on those who are already vulnerable. They are planning to do regular structured assessments across medical, functional, psychological, and social domains to identify areas requiring attention, detect early signs of deterioration, and support advance care planning When necessary, additional disciplines or services are involved to optimize support. These assessments will also generate valuable data that help us understand care needs, resource use, and outcomes across the population.
Over time we hope to be able to identify within each neighborhood, a group of high-need individuals to be followed more closely by a dedicated team or care coach, if possible in collaboration with volunteers and community initiatives. This low-threshold, proactive approach allows early intervention before crises occur.

Results and Next Steps
The INT structure allows primary care to be reorganized into smaller, well-connected networks that improve coordination across care levels, and link with community based initiatives. Implementation of a transmural collaboration model for older adults, started already with offering direct access to geriatric advice and priority day hospital slots, reducing unnecessary emergency visits. Data from screenings will guide evaluation of outcomes such as crisis reduction, care efficiency, and wellbeing.
.
________________________________________
Impact
By integrating preventive community initiatives with structured individual follow-up, Caring Leuven is building a more connected and responsive healthcare system. The Integrated Neighborhood Teams promote proactive coordination, continuity, and prevention, while strengthening primary care capacity. Above all, this approach enhances autonomy, wellbeing, and quality of life, enabling vulnerable older adults to age safely and meaningfully within their own communities