Citizens of the Netherlands receive excellent care, when they need it, insurance based funded according to the solidarity principle. Maintaining this system is a huge challenge, as we live longer and the demand for care is growing. With an increasing percentage of multi-morbidity in all age groups the need for integrated network organized care is growing at equal pace. Gradually the need to shift focus to prevention is increasingly understood, but a challenging business model is still lacking. The involvement of citizens in maintaining their health requires a focus on managing the social determinants of health. The concept of the holistic problem list and the overarching care plan provides a unique way to combine both health and disease management. Our vision is to bring control to the patient and promote coordination of all active problems across the health and social care network.
Keywords: Care continuity; health maintenance; integrated health care systems; interoperability; problem oriented medical record.