The overall aims of SUSTAIN are twofold: 1. to improve established integrated care initiatives for older people living at home with multiple health and social care needs, ensuring they are patient-centred, prevention oriented, efficient, resilient to crises, safe and sustainable; 2. to ensure that improvements to the integrated care initiatives are applicable and adaptable to other health systems and regions in Europe. In this proposal, integrated care is defined as those initiatives that proactively seek to structure and coordinate care in home environments and improve health outcomes while constraining health care expenditures. Core elements are: 1. a well-coordinated and proactive approach to health and social care needs; 2. patient-centredness by involving older people in decision-making and planning their care process, and by taking their individual needs into account; 3. (simultaneous) delivery of multiple interventions; 4. involvement of professionals from multiple disciplines. Integrated care will be improved by developing robust strategies that initially draw on the principles of the Chronic Care Model (CCM). Older people are defined as European citizens aged 65 and older with multiple health and social care needs. The focus is on this age group as complexity of care generally increases with age. To fulfil this aim, we will: 1. Identify established integrated care initiatives and conduct baseline assessments to examine their patient-centredness, prevention orientation, efficiency, resilience to crises, safety and sustainability; 2. Improve established integrated care initiatives based on the outcomes of the baseline assessments in co-creation with local key stakeholders and implement these improvements; 3. Evaluate the implementation process and identify how the established integrated care initiatives have improved; 4. Assess the applicability and adaptability of improved integrated care initiatives; 5. design and implement dissemination strategies.

Project’s activities were designed to provide data and solutions to different stakeholders in education on ways of addressing the negative implications of students' long-term exposure to poverty. Project resorted to PISA 2015 results, which confirmed students’ SES has a significant bearing on their performance, and that students from low-SES households are more likely to be low achievers. As Estonia is preforming especially well when it comes to percentage of low achievers - lowest in Europe, at 8.8%, but whose general poverty rate is comparable to other project countries, it was chosen to have its policies analysed (O1). Finally, significant for this project is conducted research which confirmed that attitudes and beliefs of teachers have direct effect on students' achievement and can support them independently of students’ SES, and that is why the second intellectual output of the project (O2) was to produce a handbook for schools and teachers on creating ideas for mitigating the effects of poverty in the form of school-based activities. The overall objective was to strengthen the capacity of schools to better support disadvantage learners in active participation in school life and in achieving better learning outcomes through: a) exploring and analysing policies and practices implemented in Estonia that enabled it to severely reduce the effect of low SES on student achievement, and drawing lessons from it; b) designing innovative school policies and practices through participative approach involving teachers, CSOs, schools, and researchers, and disseminating these. Project activities directly targeted:•Teachers: the incubator of innovative practices (C2) gathered teachers and school staff to work on tackling poverty in education and provided them with innovative practices and awareness about policies, as well as peer-learning possibilities that exist in their professional field. •Teacher-training providers: intellectual outputs of the projects were among other target groups disseminated among teacher trainers •Students with lower SES: teachers that participated in the project learnt about and as a result are better equipped to support students with lower SES. Number and type/profile of participants (for more details please see unedr 3.1)-130 relevant stakeholders from at least 17 EU, and all together 30 countries, were present at the multiplier event (E1), including teachers and school staff, as well as representatives of partner organisations. -The peer review study trip to Estonia (C1) gathered 16 participants from partner organizations; as well as local EE researchers, teachers and school staff (50).-The Innovative practices incubator /summer school (C2) gathered 34 representatives of schools, teachers and school staff, from project countries and beyond, that contributed with their knowledge to the creation of O2. -For the consultative national events (A9), partners harvested from a pool of schools and teachers that were not involved in the project, and who were targeted as either experts on the topic (CSO representatives; public offices representatives), or those who would benefit most from learning about, using, and further disseminating intellectual results that national events promoted. 91 people participated in total (in all 3 partner countries).Description of undertaken activities: -Three-day peer study visit to Estonia, hosted by the Estonian partner, with 2 representatives of each project partner (C1) correlated to the production of O1, which explored and analysed policies and practices implemented in Estonia directly or indirectly reducing the effect of low SES on student achievement, and which is published online in English.-The “Innovative school policies and practices incubator” (C2) was organized in the form of summer school and gathered more than 30 participants who worked to develop and frame innovative school policies and practices aiming at reducing the effects of poverty on students' achievement and educational experiences. This Incubator resulted in the creation and final production of the “Innovative school policies and practices handbook - Breaking the taboo - creative steps for dealing with poverty in education” (O2), published in English, Croatian, Slovenian, Macedonian and Albanian, disseminated through NEPC network and partners’ networks’ websites -Multiplier event (E1) gathered 130 participants, and besides two representatives from each project partner, included 30 teachers and school staff, and more than 70 relevant international education stakeholders, from at least 17 other EU countries. - Three consultative events (A9) (Croatia, Slovenia, North Macedonia) to present the Handbook Results: increased professional capital of the participating organisations and their staff through learning process to deal with the consequences of poverty in education.

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