This initiative is located in the western part of Sweden (Skaraborg county), in six municipalities totaling approximately 100,000 people. This initiative will concentrate on one of the six municipalities: Lidköping, which has a population of around 38,000 people (almost 22 percent 65 and over and 6 percent 80 years and older).

Beginning in the early 2000s, these municipalities in western Skaraborg have a history and tradition of collaboration between health care and social services. A large number of stakeholders were involved in the collaboration, including politicians, professionals, older people, their caregivers, and service providers.

The goal of this initiative was to create person-centred integrated care for very frail older people, which would require close collaboration between health care and social services. There are two specialised teams: the mobile palliative care team and the integrated home care team. The county (i.e. the health care authorities) funds these two teams, which serve patients in all six municipalities. The palliative care team primarily assists young cancer patients (and will not be discussed further in this presentation). The integrated home care team is responsible for serving older people with complex needs who are unable to visit the outpatient clinic.

The teams serve an average of 24 patients at a time and can be thought of as a "home hospital ward." Furthermore, in Lidköping, there is a "mobile doctor," who primarily visits older people in their homes. Home help services and home nursing care are organised in home care teams (home helpers, occupational therapists, physiotherapists, and nurses) with the goal of providing proactive, rehabilitation services to older people in their homes. Since 2009, homecare teams have worked closely with the integrated home care team and "mobile doctor" services. The municipal home care nurse is the main point of contact for the collaboration and serves as a point of contact for the integrated homecare team and the mobile doctor, as well as a partner in the municipal home care team.