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STITCH

STITCH: Seamless transitions towards integrated, sustainable, and context-aware mental healthcare

Research Line: Living with Disease / Seed Call: i4PH October 2024

Mental health (MH) is a pressing issue in the Netherlands, with nearly half of the population experiencing a MH disorder in their lifetime. Vulnerable groups, such as socioeconomically disadvantaged individuals, ethnic minorities, and LGBTQ+ communities, face even higher rates. In 2022, MH-related hospital admissions cost nearly €1 billion, excluding long-term psychiatric care. The Dutch mental healthcare system struggles with rising demand, capacity shortages, and fragmentation across formal care structures (e.g., GGZ, hospitals) and informal support systems (e.g., communities, families). Fragmentation, caused by governance issues, institutional disconnects, digital transitions, and policy barriers, leads to delays, mis-referrals, and inconsistent follow-up, focusing on symptom management rather than long-term recovery.

This systemic fragmentation also places significant strain on healthcare professionals and informal caregivers, leading to burnout due to high workloads and poor care coordination. On a broader level, it disrupts early intervention, increases chronic conditions, and drives reliance on expensive secondary care, worsening health disparities. A holistic system approach is needed to integrate care across clinical and social determinants of health. This would reduce admissions, improve care delivery, support caregivers, and enhance long-term outcomes for individuals and communities.

Objectives and Route to Impact

STITCH aims to revolutionize mental healthcare by developing a systems model prototype that encompasses the entire continuum of care, spanning formal (e.g., hospitals, GGZ, social care) and informal (e.g., community, family networks) support systems. The model will map the interconnections between actors, organizations, and processes, revealing how social, medical, contextual, and policy factors impact patient outcomes in the Utrecht region. Using the quintuple aim approach, STITCH will:

  1. Identify key players, relationships, and coordination gaps across formal and informal care settings.
  2. Map real-life ecosystems around care settings to explore how contextual factors and social determinants of health are integrated.
  3. Visualize patient flows to identify high-impact intervention points where care breakdowns or inefficiencies lead to negative outcomes, such as re-admissions.

The STITCH prototype will provide a detailed assessment of strengths and weaknesses at the patient, organizational, and system levels. This groundwork will enable future research, including the creation of a digital mental healthcare twin to simulate and optimize care pathways and support evidence-based mental health policies.

Methods and Deliverables

STITCH builds on UMC Utrecht innovations, such as the Netwerk Intake and Verhalenbank, to optimize mental healthcare by extending care beyond hospitals, improving coordination, and addressing inefficiencies. Using a mixed-method approach, the project combines qualitative insights from interviews, contextual inquiries, and co-creation with analyses of electronic patient records. By integrating knowledge from initiatives like Stadslab Overvecht and ZonMW Krachtige Leefstijlnetwerken, STITCH maps patient journeys across the care continuum to identify disruptions and improve collaboration between formal and informal networks, incorporating contextual factors and technological innovations. The research includes a literature review, patient profiling, and co-creation of a systems model prototype to pinpoint gaps and opportunities. STITCH’s findings will form the basis for larger-scale projects, including developing a “digital mental health twin” and enhancing data collaboration through federated learning infrastructure, enabling holistic and interdisciplinary advancements in mental healthcare.

Contribution to Cross-EWUU Collaboration

To ensure success, STITCH will draw on interdisciplinary expertise from multiple institutions. UMC Utrecht will contribute knowledge in collaborative governance, mental healthcare, AI, public health, and care support systems. Utrecht University will focus on addressing socioeconomic health inequalities and promoting health in disadvantaged neighborhoods. Eindhoven University of Technology will support the modeling and quantification of the systems model prototype, laying the groundwork for a future digital twin. Wageningen University & Research will bring expertise in mapping communication flows between patients and their personal networks, including both formal and informal caregivers.

Team