Ecosystem of Supports for Independent Living - Fundación INTRAS

(Ecosystem of Supports for Independent Living based on the ACIP Model - Care centred on what is important to the person)

Fundación INTRAS, with more than three decades of experience in the field of mental health, has in recent years undertaken a profound transformation in the way it supports people. This transformation is embodied in the creation of a comprehensive ecosystem of supports that replaces the logic of fragmented service provision with a flexible, coherent, and person-centered network, focused on each individual’s interests and values. Its ultimate goal is to enable every person to design and build their own meaningful life project within the community.

This ecosystem coordinates supported employment, housing with personal assistance, therapeutic services, leisure, sports, and free time, as well as technology and innovation, among others. The strength of the model lies in the fact that these resources do not operate as isolated compartments, but rather as parts of a common framework that adapts dynamically to the person’s changing needs throughout their life cycle.

The supports are specifically aimed at identifying and overcoming barriers—social, residential, occupational, emotional, or legal—that hinder full participation in the community. Each action plan starts from what the person considers valuable, and from there, personalized strategies are designed to advance their life project, removing obstacles and enhancing their strengths.

The uniqueness and added value of this initiative lies in the cross-cutting implementation of the Person-Centered on What Matters (ACIP) model. This innovative approach shifts the focus from compensating for deficits to what truly matters: each person’s values, interests, and life aspirations. ACIP is grounded in pillars such as dignity, de-pathologization, genuine empowerment, shared vulnerability, the construction of a meaningful life, and social connection, and it takes practical form in the Life Project Support methodology.

This change has also required internal reorganization. Two key roles have emerged: Support Coordination, responsible for surfacing what matters and coordinating the various resources to address identified barriers; and Direct Support professionals (DS), who provide day-to-day accompaniment, foster meaningful interactions, and ensure continuity of supports. This new structure has made it possible to better align professional roles with the logic of the life project and to offer more humane, close, and coherent support.

The innovation of this proposal lies not only in the methodology but also in the organizational structure, which has been redesigned to ensure the model’s coherence. The result is fluid and sustained support that avoids fragmentation, guarantees continuity, and strengthens people’s ability to make real decisions about where and with whom to live, what to do, and how to participate in society.

The observed impacts include higher levels of self-determination, social inclusion, and quality of life, along with a clear reduction in institutionalization processes. In this way, the ecosystem of supports based on the ACIP model not only addresses the current challenges in the field of mental health but also represents an innovative, sustainable, and transferable experience, capable of inspiring a paradigm shift toward independent living and full citizenship.

Responsible Department

The implementation of the care model is cross-cutting and coordinated by the Directorate of Social Challenges and Studies, in close collaboration with the different Territorial Directorates and Service/Unit Heads (Community Care, Training and Employment, Supported Housing, Memory Clinics, Personal Assistance). This transversal approach ensures methodological coherence of ACIP across all services (residential, community-based, therapeutic and employment), supported by internal training, supervision and continuous improvement.

Target group

The interventions are aimed at people who identify barriers that limit their active and full participation in the community, and who request support to face and overcome them. The provision of such support is subject to the availability of resources and services within the operational ecosystem of the Foundation. These barriers may be linked to different areas, including:

the social and community environment (stigmatisation, isolation, lack of support networks),
access to and maintenance of adequate housing,
labour market and educational inclusion,
personal and psychological factors,
as well as legal and administrative aspects.

Methodologies and approaches

The initiative is developed under the Model of Care Centred on What Is Important to the Person (ACIP) which constitutes the methodological core of all the services involved. ACIP proposes a paradigm shift: moving from addressing needs through a compensatory logic to placing supports at the service of what is valuable and meaningful to each person.

This model is implemented through the methodology of the “Support Service for the Life Project”, which is structured around:

Participatory planning: each person defines, together with support professionals, their own life project, identifying goals, values and aspirations.
Interactions centred on what is important: professionals establish horizontal, authentic relationships based on dignity, shared vulnerability and social connection.
Flexibility and continuity of supports: integration of employment, housing, personal assistance and autonomy-promotion services into coherent pathways that accompany the person throughout the different stages of their life.
Co-production: service users actively participate in the design, evaluation and improvement of supports, ensuring that these respond to their real priorities.

Innovation and creativity

The main innovation of this initiative lies in the cross-cutting application of the ACIP model to an entire ecosystem of supports (throughout the whole Foundation). This entails:

A common and coherent framework that unifies traditionally fragmented services (employment, housing, personal assistance) under a single logic focused on what is important.
A transformative approach that goes beyond needs-based care, placing at the core those elements that provide meaning and sustainable motivation to a person’s life.
Interactive and horizontal methodologies that break away from paternalistic care and promote authentic, empowering relationships.
Transferability: ACIP integrates tools from behavioural science, contextual psychology and person-centred planning, making it applicable in different contexts and for groups experiencing vulnerability.

In this sense, the project not only introduces a new way of working, but also transforms the organisational culture, infusing all levels of care with a perspective grounded in dignity, autonomy and the construction of meaningful life projects.

Support to Independent Living

The support ecosystem based on ACIP promotes independent living in line with Article 19 of the UN Convention on the Rights of Persons with Disabilities and the European Pillar of Social Rights. It does so through:

Real choice: the person decides where and with whom to live, what type of job to undertake and what supports they need at each stage of their life.
Self-determination and empowerment: the accompaniment does not focus on “treating” or “correcting”, but on training skills so that the person can stay on course towards what they consider important, even in adverse situations.
Community participation: natural and community environments are prioritised over institutional settings, strengthening social inclusion and belonging.
Personalised and continuous supports: a flexible pathway is offered to accompany life transitions (e.g. access to employment, moving into independent housing, participation in social life) without disruption.

In short, the initiative demonstrates that it is possible to build a system of supports that makes independent living effective, not only as a legal right but also as an everyday lived experience for people with mental health problems.

Staff and resources

This major change has required the mobilisation of a broad multidisciplinary team and a solid organisational infrastructure.

On the human side, the Foundation has professionals from different backgrounds: clinical and community psychology, social work, occupational therapy, social integration, employment specialists, personal assistants, housing support staff, as well as territorial and service coordination teams. This diversity of profiles makes it possible to address, in an integrated way, the various barriers (social, residential, occupational, personal, legal) that may limit participation in the community.

The organisational change has led to the creation of two key roles:

Support Coordination, responsible for bringing out “what is important” and orchestrating the different resources around the person’s life project.
Direct Support Professionals (AP), who provide accompaniment in daily life and foster meaningful interactions, ensuring continuity and coherence in supports.

In terms of material and technological resources, the Foundation has a network of 29 centres and services located across Castilla y León and Madrid, transitional housing, inclusive employment programmes, etc. In addition, the implementation of the corporate platform MN Program makes it possible to unify information, make the Life Project visible across all services, and ensure traceability in the evaluation of goals and supports.

At the training level, more than 100 hours of internal training were invested in 2024, complemented by specialised modules in 2025 and a system of case supervision that reinforces the practical application of ACIP across all teams.

This set of human, structural and technological resources guarantees the viability and sustainability of the ecosystem, ensuring that each person has the necessary supports to progress in their life project.

Identifying specific needs

The initiative is based on a co-production approach, in which each person, together with their meaningful support network, actively participates in identifying their needs and in defining the objectives and actions of the Support Plan.

Needs are not addressed through diagnostic categories but emerge from each individual’s personal history, values, and aspirations. This makes it possible to build personalized pathways in areas such as housing, employment, training, community participation, self-care, and coping with distress.

The model integrates formal supports, natural supports (family, friends), and community supports (local resources) to make an independent and meaningful life possible. Professional teams are trained to sustain decision-making processes, accompany life transitions, and adjust supports according to motivational changes or crisis situations.

Regular reviews are carried out with the person and their support network to evaluate progress, identify new barriers, and redesign the necessary supports, thus ensuring a flexible intervention centered on sources of inexhaustible motivation for the individual.

Other stakeholders and partners

The ecosystem of supports developed by Fundación INTRAS is built not only on its own resources but also through a wide network of alliances and collaborations that strengthen the organization’s capacity to respond to the needs and barriers identified by individuals.

First and foremost, families and caregivers stand out as the closest natural support network. Their involvement is fostered through training, guidance, and participation processes, ensuring coherence between professional resources and the person’s emotional and community environment.

At the institutional level, the Foundation maintains close coordination with regional and local administrations (the Social Services Administration of Castilla y León, Provincial Councils, Municipalities), which contribute to the funding, monitoring, and development of housing, employment, and personal assistance programs. This collaboration makes it possible to align the PCWM ecosystem with public policies on inclusion and independent living.

In the social and healthcare field, the Foundation works together with mental health and primary care services, ensuring continuity of care and preventing individuals from becoming trapped in institutionalizing dynamics.

The business and associative fabric also plays a key role in supported employment pathways, providing internships, contracts, and work experiences that become vehicles of identity and belonging.

Finally, the Foundation collaborates with universities, research centers, and European institutions, which makes it possible to incorporate applied innovation, generate evidence on outcomes, and transfer the model to other contexts.

Taken together, this network of actors ensures that supports are not confined to the institutional scope of the Foundation but are rooted in the community, fostering a full and sustainable independent life.