The Living Lab in Ageing and Long-Term Care: A Sustainable Model for Translational Research Improving Quality of Life, Quality of Care and Quality of Work

The Living Lab in Ageing and Long-Term Care was founded in 1998 by the structural collaboration between a nursing home and Maastricht University. The impetus was a desire to embed scientific research within long-term care for older people (5). In 2000, the collaboration was expanded with two other long-term care organizations and Zuyd University of Applied Science (responsible for training of bachelor educated professionals, e.g. nurses, physiotherapists, social workers). Today, the Living Lab is a sustainable and successful partnership of Maastricht University with seven long-term care providers, Zuyd University of Applied Sciences and two vocational training institutes (responsible for training of e.g. nursing assistants).

The Living Lab is not a physical space, but a network in the southern part of the Netherlands in which researchers collaborate through continuous discussion with end-users such as older persons and their families, client representatives, professionals, health care directors, policy makers and teachers. It covers approximately 110 long-term care facilities (e.g. nursing homes, assisted and group living facilities) as well as professional home care, and includes about 30,000 clients and more than 15,000 staff (see Box 1).

Two aspects of the Living Lab model require funding: a) infrastructure, and b) research. Partner organizations are the principal funders with respect to infrastructure, while grants provide the primary financial support for research.

Long-term care organizations fund infrastructure by paying for the scientific Linking Pins. Formally, the long-term care organizations have no allocated budget for scientific research. They account for these amounts through the impact research projects have on innovation and improvement of practice for clients, their relatives and staff. In addition, all partner organizations contribute in kind, through allocating resources enabling staff to work on Living Lab projects (including time and training). Maastricht University finances infrastructure by paying for the coordination of the Living Lab, including supportive staff and communication. The University also covers the costs of the workplaces of practice-based Linking Pins at the university. As this model has proven its sustainability over the last 20 years, the Dutch Ministry of Health, Welfare and Sports has decided in 2018 to financially support the infrastructure investments with €1 million, strengthening the Living Lab’s infrastructure and power.

The Living Lab partnership uses scientific research to address problems identified by people who live and work in long-term care. The continues dialogue between researchers and all end-users has identified three main research themes have been identified for the Living Lab (Figure 2):

The first research theme focuses on improving the daily life of older people and their families through improvements in support, delivery of care services and treatment. This research takes place at the micro level of care service delivery, that is, in the direct care relationship with older people, their families and professionals. Examples of these research projects include the National Prevalence Measurement of Quality of Care (https://​nl.​lpz-um.​eu/​nl), improving palliative care for people with dementia (8) or developing diagnostic techniques for heart failure in nursing homes (9).

Scientific knowledge on how best to equip professionals in doing their job is imperative to improve support and care service delivery. The second research theme, therefore, focuses on staffing and innovation management in long-term care. Example projects include optimal skills-mix, team culture and organizational climate (10), development of a decision-support application for community nurses and case managers in dementia care (11), all aimed at evidence-based innovation of care service delivery and support.

Radical alterations are sometimes necessary to change current long-term care practice. The third research theme includes studies on the impact of redesign in long-term care practice, focusing on how care service delivery can be improved in order to better meet the needs and wishes of older people and their families. Example projects include evaluation of green care farms as an alternative to traditional nursing homes (12), development and evaluation of a geriatric rehabilitation care pathway (13) or population-based financing in home care (14).

The Living Lab intends to improve the quality of scientific research. This includes the development of adequate assessment instruments for important outcome measures in long-term care, such as the identification of pain in people with dementia (15) or assessment of daily life in nursing homes (16). Scientific research conducted within the Living Lab uses a variety of research methodologies and paradigms, including pragmatic trials and action-based research approaches.

The Living Lab also aims to improve the quality of education. It is important to encourage enthusiasm for young people to choose a professional career in the field of geriatrics and gerontology and to build an infrastructure of health care innovators for long-term care. Up-to-date scientific knowledge is implemented in educational programs for future students on all levels: from vocational training to bachelor’s and master’s degree programs. The Living Lab also enables students to work within innovative research projects. To illustrate, the Living Lab developed in 2018 a new bachelor’s program for nurses led by Zuyd University of Applied Sciences. Unique to the program is that students are employed by one long-term care organization during the study program but receive training and education in a learning network across the Living Lab partner organizations. Themes such as leadership, palliative care, innovation and technology are being taught directly by professionals of the long-term care organizations and researchers working within the Living Lab. Educators from Zuyd University of Applied Sciences and the vocational training institutes provide innovative didactic techniques and support. Furthermore, we have integrated Virtual Reality techniques have been integrated into university courses for bachelor’s degree students to learn about innovations in home care (17). At the same time, this educational module is used within the partner long-term care organizations to train home care staff in principles of reablement (18).

Over the past 20 years, the Living Lab on Ageing and Long-Term Care has had a highly significant scientific and societal impact. For direct partners, the Living Lab has increased enthusiasm, (scientific) awareness and expertise of staff through structural participation in projects, education and sharing of experiences at annual symposia. The Living Lab provides a safe, non-competitive environment, in which there is space for people to engage in a dialogue and to experiment. This creates a learning network of researchers, older people and their families, and professionals to encourage innovation in long-term care practice. This goes beyond the borders of the Living Lab, as work visits and exchanges have been organized with other groups of long-term care researchers, such as in the United Kingdom (My Home Life, Leeds NICHE).

Scientifically, the Living Lab has enabled the development of new knowledge in a variety of areas within long-term care. In its 20 years, the research has led to the publication of over 750 peer-reviewed scientific papers in international journals and 25 PhD theses. The partnership is attractive for external funding agencies, which adding to its earning power. Tools and interventions have been developed to support professionals in long-term care (9, 11, 13, 15). The Living Lab has developed knowledge on innovative forms of long-term care, such as small-scale homelike facilities (12, 19) and function-focused care at home (18).

The Living Lab research has had an impact on national policy development through changes in legislation (e.g. reduction of restraints and involuntary treatment) and changes in policy (e.g. relationship between staffing and quality of care in nursing homes). Furthermore, it has taken a role in the societal debate on long-term care, by organizing public meetings for citizens and by developing factsheets for lay audience and video messaging. Its meeting in December 2018, where the Living Lab celebrated its 20th Anniversary, attracted almost 1100 people, including older citizens, long-term care staff and students.

The Living Lab provides an attractive environment for young students to gain enthusiasm for working in long-term care. Students can participate in research projects and can take on new positions and leadership roles. Furthermore, the Living Lab assist in training people to become health care innovators within long-term care.

Sharing knowledge about the Living Lab may facilitate others in setting up a similar model for creating a partnership between research and long-term care practice. It is important to start small with a selected group of motivated partners. Intrinsic motivational commitment from these parties is necessary for innovation, change and improvement. The establishment of the partnership should require no extra funding, only cash and in-kind funding from the partners to set up the collaboration. Starting small will enhance the success rate of selected projects and increase the belief that such translational model may really work. This can increase enthusiasm from other interested partners and is necessary to develop a mutual trusting relationship among partners, which is a key element for success. The network can then gradually be increased to enable and jointly develop the mission and vision of the Living Lab and to train researchers and Linking Pins, building a full infrastructure within the individual partner organizations.

Expectations from all partners should be managed carefully and should not be set too high, especially at the beginning. No major results can be expected immediately after the start. For example, a partnership will not solve policy issues or practical problems in daily care practice for the whole organization right away. The driving force behind the Living Lab is the reciprocity and trust among partners. To create a meaningful collaboration, it is necessary that both partners have a vision on collaboration and experience benefit to create a win-win perspective. This requires commitment of partners, efforts in establishing a trusting relationship and confidence in each other. Sympathy for each other is crucial in this process. This accounts for sympathy between academia, practice, and education but also across the various disciplines working within the Living Lab. It takes an effort in trying to understand each other’s viewpoint. However, improving the quality of life for older people and their families, quality of care and quality of work for staff in long-term care, unites the partners. Equity and finding tailor-made solutions based on scientific research for individual partners is part of the success of the Living Lab.

Maastricht University’s Living Lab on Ageing and Long-Term Care may be viewed as a best-practice example, and its approach has been adopted by other (inter)national groups. The Nurturing Innovation in Care Home Excellence partnership was established in 2018 in Leeds (United Kingdom) based on the Maastricht’s Living Lab blueprint. Furthermore, Maastricht’s Living Lab was a model partner in the Horizon2020 Twining Project ALTHOUR (Assisted Living Technology for the Health Tourism sector), in which its’ structure and research was a prototype example of a Living Lab structure to prepare for the set-up of a ‘Health Tourism Living Lab’ in the Lisbon area (Portugal) by the University of Lisbon. After the start of the Maastricht Living Lab, there are five other academic networks established in long-term care in The Netherlands, situated in Amsterdam, Leiden, Nijmegen, Tilburg and Groningen. They all act from the same principle, aiming to embed scientific research into daily LTC-practice. To some extent, differences exist in organization, interdisciplinarity and research focus. However, they have all adopted the linking-pin model as developed by Maastricht. Nationally, the 6 networks meet regularly to exchange experiences and good practices and also to discuss strategies to further implement evidence based practice in long-term care, to ultimately cover the total LTC-sector in the country.

There is no fixed scheme to set up a partnership between academia and long-term care providers and associated organizations, as one size does not fit all. Both within and between countries, organizational culture, structure, and financing of long-term care and research differ, affecting the organizational structure of a partnership. However, in our opinion, the interdisciplinary character and Linking Pins are responsible for the success of the Living Lab on Ageing and Long-Term Care over the past 20 years. This creates a sustainable learning network across organizations, which is highly recommended to create a research culture in long-term care (20).