active and healthy ageing: b3 integrated...

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EIP AHA B3: Expressions of commitment

Active and Healthy Ageing: B3 Integrated Care

Summary of Expressions of Commitment:

Names: Organisations; Activities; Executive Summary of commitment

June 2012

Prepared by Andrew Ruck,

Consard Limited

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Contents

Page #

Introduction 4

EIP AHA B3: Integrated Care Submissions received: Ref # Organisation submitting commitment 1 Departamento de Salud Valencia‐La Fe 5 2 Católica Porto 6 6 COCIR 6 7 Municipality of Palaio Faliro 7 8 Coöperatie Slimmer Leven 2020 8 9 European Wound Management Association (EWMA) 9 10 European Federation of Nurses Associations. 10 11 DEPARTAMENT DE SALUT – GENERALITAT DE CATALUNYA 11 12 Agencia Valenciana de Salud 12 14 European Platform for Patients’ Organisations, Science and Industry 13 15 A, B,

Department of Health, Social Services and Public Safety 14

16 IESE Business School 16 17 A,B,C

Region North Denmark 16

18 Novartis 19 19 Department of Health and Consumer Affairs of the Basque Government 20 20 University of Alicante 21 21 CORAL 21 22 Life Supporting Technologies – Universidad Politecnica de Madrid 22 23 Servicios de Teleasistencia S.A. (ST) 23 24 Hospital Clinic ‐ IDIBAPS 24 25 IRCCS, Salvatore Maugeri Foundatio 25 26 Centre for Health and Technology, University of Oulu 26 27 e‐Health Unit, "Sotiria" Hospital, 1st RHA of Attica 26 28 Europäische Vereinigung für Vitalität und Aktives Altern eVAA e.V. 27 29 Fondazione Bruno Kessler (FBK) 28 30 A Radboud University Nijmegen Medical Centre 29 32 Fondazione Democenter‐Sipe 30 33 Assembly of European Regions (AER) 31 34 IK4 Research Alliance 32 35 Agenzia sanitaria e sociale regionale (Emilia Romagna) 32 36 CSI‐Piemonte (Consortium for Information Systems) 33 37 University of Valencia. (UVEG) 34 38 Region Syddanmark (Region of Southern Denmark) 35 39 New Tools for Health 35 40 SERMAS‐HOSPITAL UNIVERSITARIO DE GETAFE 36 41 EHTEL 37

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42 European Connected Health Alliance (ECHAlliance) 38 44 Philips Healthcare 38 45 NHSScotland, co‐ordinated by NHS 24 39 46 Mútua Terrassa 40 47 NHS Yorkshire and the Humber 41 48 Spanish Collaborating Centre of the Joanna Briggs Institute (Nursing and

Healthcare Research Unit) 42

49 Dutch Associated Health Insurance Companies 42 50 EUREGHA 43 51 Zealand Denmark 44 52 FEDERICO II UNIVERSITY 44 53 ANDALUSIAN SCHOOL OF PUBLIC HEALTH 45 54 Institute of Health Carlos III 46 55 Regional Healthcare Agency of Puglia 47 56 Servicio Andaluz de Salud (Andalusian Health Service) 47 57 Région Languedoc Roussillon 48 59 European Centre for Social Welfare Policy and Research 49

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Introduction

This document lists the organisations which submitted validated responses to the request for expressions of commitment to Thematic Area B3: Integrated Care. The document contains the (unedited) descriptions provided by the organisations which submitted a commitment as well as the executive summary of their proposed commitment as submitted.

Duplicate entries have been edited, and multiple expressions of interest from (apparently) the same organisation have been grouped. Some responses submitted were assigned to other working groups.

In total,

70 commitments were received

52 organisations were invited to attend the first Action Group Meeting

15 organisations were not invited to the first Action Group Meeting

7 organisations submitted more than one commitment

3 duplicate (identical commitments were received from the same organisation

1 organisation submitted a commitment but with critical information missing

If there is a misunderstanding, apologies and please let me know.

Document prepared by Andrew Ruck on 24th June 2012

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EIP AHA B3: Integrated Care Submissions received:

Person submitting expression

First name

Surname

Name of Org. Org. Type

Organisation Description and Core Activities

Executive Summary of Commitment Proposed

Bernardo Valdivieso Departamento de Salud

Valencia‐La Fe

Health provider

The Health Department Valencia‐La Fe is one of the 23 geographical areas defined within the Valencia Health Region in order to manage and provide the public healthcare services to the region’s population. The Health Departments are coordinated by the Valencia Health Agency (AVS) but they receive and manage directly the funds provided by the National Ministry of Health and they have to supply primary, secondary and tertiary care to this population. Each of them are coordinated by a Reference Hospital (in our case Hospital La Fe, among the biggest in Europe), and are responsible for healthcare delivery and policy making within the framework provided by the Ministry. The funding received follows a capitation model and each of the departments has the possibility to organize internally and assign priorities according to their strategy as long as the overall framework is respected. The Health Department contains 1 hospital, 16 Primary Health Areas, plus research, evaluation and innovation.

The Health Department Valencia‐LaFe has developed a programme for the integrated management of complex chronic patients, with the aim to cover approximately 3000 patients, using technology for remote monitoring patients, combining primary and secondary care, including different types of health professionals and support for self‐care and informal care‐givers. This service started in autumn 2011 and could easily include added tools for support of the patients and be one of the sites for piloting (This pilot is funded by a public‐private partnership, including the AVS, the hospital and different companies interested in it). The service will be complemented by a randomized control trial that starts in April 2012 aiming at gathering clinical and cost related evidence about the deployed service. The trial will evaluate the impact of two different interventions in high complexity chronic patients selected by means of a risk prediction stratification tool. The study will include 495 patients, the follow‐up period will be 12 months and the indicators that will be collected will be focused in the clinical variables for each type of chronic patient, the health outcomes (quality of life related to health, mortality, satisfaction, cognitive function and dependence) and the usage of health resources. All these activities are completely included within the healthcare processes of the health department and will be fully operational within the first semester of 2012.

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First name

Surname




João Queiroz e Melo

Católica Porto Research/academ

ia

ICS is the Faculty of the Portuguese Catholic University that is dedicated to teaching (undergraduate and postgraduate), health research and nursing care: Nursing, Palliative Care, Wound & Tissue Viability, Quality Management in Health, Occupational Health, Control of infection Associated with the Provision of Health Care and Health and Geriatric Care. This faculty is located in two different campi, in Lisbon and in Porto. As part of the Catholic University connection and support to charities linked or not to the church is significant, particularly in the north.

The objective of this action is to implement a remote network of telemedicine for chronic patients, aiming at increase in the patients the knowledge for appropriate self health care and also for remote surveillance of their diseases and health state avoiding the time and resources consumption for a consultation. The size of the network, mostly institutionalized elderly population and the characteristics of geographic dispersion in which it is deployed away from the centers and limited access to care and establish priorities for intervention care training for caregivers and remote monitoring (preventive and continuity monitoring of wounds and pressure ulcers). It will also be implemented to control heart failure through telemedicine and the preparation and referral of elderly patients for consultations and preparation prior to surgical interventions, including the use of digital stethoscopes and observation followed (monitored) at a distance.

Nicole Denjoy COCIR Other

Founded as a non‐profit trade association in 1959, COCIR represents the Radiological, Electromedical and Healthcare IT industry in Europe. Our members play a key role in improving healthcare both in Europe and worldwide through the use of innovative diagnostic and IT technologies and solutions. COCIR works to promote regulatory and quality controls that respect the quality and effectiveness of medical devices and healthcare IT systems without compromising the safety of patients and users.

The Assembly of European Regions (AER), the European Federation of Nurses (EFN) and COCIR propose to organise a road show in selected EU Member States to help European regions develop innovative integrated care models including innovative technologies through the use of EU structural funds. The goal is to encourage these targeted regions to use the available structural funds for health (remaining and post 2013 cohesion funds) in order to replicate other European regions’ best practices in patient centric, integrated care models. One best practice that has been identified is Northern Ireland. Concretely, AER, EFN and COCIR propose to liaise with regional authorities, local stakeholders and the competent authorities (National Minister of Health, Minister of Finance, managing authorities, etc) in selected Member States to raise awareness about the

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availability of the funds, how they can contribute in building cost‐efficient integrated care models, and how to best manage and use them. The consortium will offer a selection of best practice examples in the field of integrated care and support the regional and national authorities to adapt and implement successful practices in their territories. The work would kick off in Poland and extend to other countries such as Rumania or Slovakia. The aim is to help build political will in using the structural funds to invest in health and implement integrated care models through the replication of recognised European best practices.

Anastasios Rentoumis Municipality of Palaio Faliro

Public authorit

y

The Municipality of Palaio Faliro is one of the most historic municipalities in Athens. It is situated in the southern sector of the Region of Attica and has a population of around 100.000. It is a densely populated urban centre and relies mainly on tourism and recreational activities for development, since it has a well‐developed seafront. Together with the neighbouring Municipalities of Alimos and Agios Dimitrios, a population of about 250.000 citizens is covered. Since 2010, a new legislative framework (KALLIKRATIS) sets out the boundaries for health and social services at regional and municipality level. Primary care, public health, prevention, health promotion, health education and social services will gradually be planned, provided, financed and monitored by Municipalities, having as a start point the beginning of 2013.

A pilot will be implemented focusing on chronic conditions monitoring and management that constitutes the greatest financial and social burden of today’s National Health Systems at a global level. More specifically our pilot will focus on senior patients suffering from diabetes mellitus Type II and their carers both formal (e.g. diabetes nurses, social care workers, treating physicians) and informal (family, friends, third sector in general). An innovative ICT platform will be developed to cater for the needs of the seniors and the carers in a non invasive cum efficient way. This platform will consist of various modules such as lightweight portable devices measuring vital parameters with built in communication capabilities for transferring data to a master station (web enabled application) so they will be available for the professionals to browse through, always taking into consideration the requirements emerging from these data sensitive nature, self management portals, etc. The pilot will make special provisions for the integration of care implementing a model spanning through the social and health sectors and involving all relevant stakeholders such as the community, local administration, industry, health and social care professionals,

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academia, etc.

Peter Portheine Coöperatie Slimmer Leven

2020

Other

The cooperative Slimmer Leven 2020 has its basis in the South‐East Netherlands and is supported by provincial and local government. The 70 members have joined forces to achieve a shared ambition and seek for breakthroughs in strengthening high quality of life for people by development and broad deployment of technological and innovative concepts value‐added for citizens. The cooperative distinguishes eight different partners: local and regional governments, health care providers, hospitals, housing corporations, wellbeing organizations, knowledge institutions, development agency, health insurance and private companies. The purpose of the cooperative is non‐profit. The goal of the cooperative is to disseminate knowledge and best practices between members, but also with parties on national and European level in order to stimulate wide scale deployment and exchange and development on new ideas. Therefore results from European projects will be shared and are available.

An important objective in the Care Circles project, that is carried out by 20 healthcare organisations in the South‐East of the Netherlands is working together to provide a higher quality of care and extra security during the night for people in need of care. Because these parties collaborate by using shared facilities as a care calling center and shared night teams who provide care for everybody in a specific area during the night irrespective of from which organization a specific person is a customer. Electronic equipment that is being used, are fir example sensors, movement sensors, door switches, mat alarms, and GPS transmitters. For example, when somebody has fallen or is wondering around (in case of dementia), these devices transmit a signal to a health care centre. The dispatcher at the centre assesses the situation and sends an assistant or an emergency service to address the question.

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Jan Apelqvist European Wound

Management Association (EWMA)

Advocacy

organisations

The European Wound Management Association (EWMA) works to promote the advancement of education and research into native epidemiology, pathology, diagnosis, prevention and management of wounds of all aetiologies. EWMA is an umbrella organisation linking 47 national wound management associations in 36 countries as well as 19 international partners and collaborators. In total, EWMA represents more than 23,000 clinicians working with wounds across Europe. These members reach a wide number of health professionals and health care providers through education and guidance. EWMA facilitates the educational dissemination of its expertise and promotes ‘state of the art’ treatment. EWMA actively supports the implementation of existing knowledge in all aspects of wound management by advocating our evidence to stakeholders. As a multidisciplinary organisation, EWMA strongly advocates a multidisciplinary approach to wound care as a model of organisation of care for others to follow.

EWMA promotes a multidisciplinary approach to wound care in order to prevent wounds, increase the quality of treatment and save resources. Through dissemination of knowledge and comprehensive implementation strategies EWMA works to decrease morbidity, to lower hospitalisation and allow early diagnosis of underlying chronic diseases as well as preventing amputations. This holistic approach provides better conditions for the elderly population of Europe. EWMA’s commitment is to substantially reduce the prevalence of wounds across Europe through the education of clinicians, introduction of modern wound treatment and patient empowerment with a multidisciplinary approach. Furthermore, EWMA supports a process of innovating health care provision through telemedicine application. An example of EWMA’s work is the conduction of the Leg Ulcer Project (LUP) in one region of the Czech Republic, Poland and Slovenia in 2007‐11 as well as training in Hungary, Slovenia and Austria. LUP has successfully piloted the development of guideline based education and training of local health care professionals. The results have not only provided evidence of significantly reduced costs of treatment but also of reduced leg ulcer prevalence as well as better educated home care personnel. EWMA considers the possibilities for the roll‐out of this project in the rest of Europe.

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Paul De Raeve European Federation of

Nurses Associations.

Advocacy

organisations

The mission of the EFN is to promote and protect nurses and the nursing profession with particular reference to the EU, by lobbying the European Institutions. The EFN is the independent voice of the nursing profession consisting of National Nurses Associations from 34 European countries, working for the benefit of 6 million nurses. The EFN is strong on working towards a unified voice for nursing in the EU. The EFN shall strengthen the status and practice of the profession of nursing and the interests of nurses in the EU & Europe. Objectives: ‐ To ensure that nurses and nursing is central to the development of Social and Health Policy and its Implementation in the EU and Europe. ‐ To support and facilitate a qualitative and equitable health service in the EU and Europe by a strategic contribution to the development of a sufficient, effective, competent and motivated workforce of nurses. ‐ Strengthening and developing EFN key role as bridge between NNA and decision‐makers in the

The ‘Identification and regional implementation of Integrated Care Models’ fits within the 4th line of action of the SIP – “spread and promote successful innovative integrated care models for chronic diseases amongst older patients”. The EFN is focussing mainly on new strategies on continuity and integrated care systems, with a strong component of sustainability of health systems. At the last EFN General Assembly in Ljubljana (19‐20 April), several integrated care models were identified within EFN membership. These models have implemented innovative approaches (organizational and administrative innovations, new business models, well defined patient‐specific care plans and their combination with ICT systems) and have shown they contribute to reducing avoidable/unnecessary hospitalisations, enhancing patient self‐ management, increasing quality of life, providing evidence on cost effectiveness respectively. The implementation of these models can be addressed within existing European, national and regional EU funding, specifically the Public Health Programme, the Competitive and Innovation Framework, the 7th FP, and Structural and Social Cohesion Funds (EPSCO Council June 2011), among others. The EU Structural and Cohesion Funds are available to address the challenges of the economic crisis, the development of the EU workforce for health and skill development, employment and growth.

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ANTONI DEDEU DEPARTAMENT DE SALUT – GENERALITAT DE CATALUNYA

Public authorit

y

The Department of Health of Catalonia (DoH is the main Health Authority in the Region of Catalonia, Spain. Catalonia has a population of 7,600,000 and the DoH has full competences in the financing, commissioning and provision of health services, as part of the decentralised model of the Spanish Health System. The DoH is solely responsible for defining and implementing the health strategies for Catalonia. Furthermore, the DoH promotes the development and use of information and communication technologies (ICT) to enhance the health and social network, to provide a model based on personalised care to all citizens. To achieve this goal, the DoH has followed a governing model built on a participative basis with stakeholders from various sectors; it has also created two organisations, the Catalan Agency for Health Quality and the TicSalut foundation to run solid and planned policy to deploy ICT. The DoH, jointly with the Department of Social Welfare and Family has given a special focus to t

The CROSSING‐REG (C‐REG) initiative will provide the EIP on AHA with added‐value to an on‐going process in a real scenario based on the implementation of an integrated care approach for chronic diseases at a regional level. The rationale of C‐REG is based on demographic and epidemiological evidence. The target population of this project is the 100% of the citizens of Catalonia and the geographic scope is all the territory of Catalonia in a 4‐year period. According to the EU tendency, 18% of the population of Catalonia is over 65 years old and 4% is over 80 years old, and Active and Healthy Ageing is also a priority for Catalonia. Moreover, a chronic care approach has been introduced taking into account the integrated care perspective. The development of home health care services and other specific alternatives to acute hospitalization in nursing homes to prevent and reduce avoidable emergency admissions in acute hospitals and A&E visits has been planned in C‐REG. Acute hospital beds will be transformed into sub‐acute beds accessible from Primary Health Care. Specific focus will be given to promote and encourage patients’ self‐management of chronic diseases and to play a more active role in their care. This will be achieved with the involvement of patients in participative educational programmes and also with initiatives such as the Expert Patient programme. Open access and friendly use of the “Personal Health Folder” through internet and mobile applications for chr

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Domingo Orozco‐Beltrán

Agencia Valenciana de

Salud

Public authorit

y

Agencia Valenciana de Salud (AVS) is an autonomous organism assigned to Valencian Government (Generalitat Valenciana), aiming at managing and administrating the Valencian healthcare system and providing healthcare to the 5.1 million inhabitants of the Valencian Community (Eastern Spain). AVS includes more than 11.000 MDs in its staff, and it has an EHR system pioneer in Spain that covers virtually the whole Valencian population. Although the main mission of AVS is to provide healthcare, its research and development activities are also significant: AVS has participated through its research foundations in 11 FP6 and FP7 research projects funded by the European Commission. The regional government created seven foundations to manage the research of the seven largest hospitals in the Valencian Community. In 2009, the FISABIO foundation was created to support the research projects and clinical trials of hospitals and primary care centers not previously served by the other foundations.

The program's goal is to design and evaluate the impact of a new integrated care model for patients with chronic diseases in the Valencian Community, based on the use of Information and Communication Technologies (ICTs). This new care model is sustained on the basis of a shared action between the primary care team and other healthcare levels and areas, and supported in a unique electronic health record. The specific objectives of the program include those that can contribute to the sustainability of the chronic care system, reducing the associated overall costs, while improving the quality of the health status of patients. The first program's scope is limited to a target population composed of up to 12000 patients distributed according to assumptions of population stratification by clinical risk profile (high‐risk patients, average‐risk patients, low‐risk patients), and four participating healthcare centers. The program, that will be scalable to the whole region, focuses on four chronic diseases and their possible combinations: ‐ Type 2 Diabetes Mellitus ‐ Chronic obstructive pulmonary disease (COPD) ‐ Heart Failure ‐ Hipertensión. Considering the combination of multiple diseases and risk profile of patients, 16 assistance programs are defined. The technological equipment includes connectivity hardware and technological support, and devices for biosignals acquisition. Multiple functionalities have been identified for patients and for proffesional staff.

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Jacqueline Bowman‐Busato

European Platform for Patients’

Organisations, Science and Industry

Other

Founded in 1994, Epposi is an independent, not‐for‐profit, partnership‐based and multi‐stakeholder think tank based in Brussels, Belgium. Our governance structure enshrines equally weighted decision‐making between our core member constituencies: patients' organisations, science and industry, as well as fostering collaboration with other key stakeholders: EU, national and regional policy‐makers, payers, health and social care professionals, ethicists, health economists and employers. Our research programmes are designed to facilitate multi‐stakeholder solutions to bridge the gap between innovation in healthcare and improved public health outcomes by providing members and the wider public with high quality independent research, capacity‐building, knowledge exchange and dissemination. Epposi is also a formal stakeholder supporting the work of the Steering Committee of the European Innovation Partnership on Active & Healthy Ageing in relation to Care and Cure and horizontal actions.

ENCOMIUM is a joint, pre‐competitive forum of stakeholders representing patients, academia, industry, payers, healthcare professionals and providers to create the framework and necessary tools to stimulate future marketplaces with innovative business models to bring about sustainable changes in chronic conditions care delivery. The general objective of the project is to provide European societies with a clear systematic modus operandi on how to prepare and execute changes in current delivery of care leading to provision of integrated care based on innovative business models and technologies. Its ultimate aim – the creation of a European Chronic Conditions Management Institute with ready‐ to‐ go products and services in the field of chronic conditions management – will provide a unique strategic answer to the missing gap of building capacity in chronic conditions management in Europe. The project scales up Epposi's research to build a holistic, non‐disease specific model for the management of chronic conditions in Europe, taking into account medical, socio‐economic and technology dimensions. Taking Epposi's CCM framework built upon a multi‐stakeholder consensus as a basis, main outputs of ENCOMIUM project within 18 months are: quality seal benchmark system, connected patient‐centred workflow protocols, transformation management models, tools and techniques, co‐design of innovative products and services and sustainability business plan for the next project phase.

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John Farrell Department of Health, Social Services and Public Safety

Public authorit

y

Under the delegated responsibility of the Department of Health, Social Services and Public Safety the Centre for Connected Health and Social Care has been established to promote improvements in patient care through the use of technology, and to fast track new products and innovation in the Health and Social Care system in Northern Ireland. The primary purpose of the CCHSC is to improve the patient and client experience, and to provide better quality and more effective care. By supporting the more efficient delivery of services, it will also enable the healthcare system to respond better to the future needs of the population.

A. TNI is a regional ‘end‐to‐end’ managed service designed, procured and implemented by the NI Centre for Connected Health & Social Care and provided by a consortium comprising Tunstall Healthcare UK, Fold Housing and S3 (TF3). It provides remote telehealth monitoring services to 3,500 patients per annum who are suffering from chronic conditions (the majority of whom are elderly). Clinicians in the Trusts identify patients who are suitable for the service and refer them using an on‐line form, selecting whether the patient is to receive a Triage service (in which case patient‐specific vital sign parameters are set) or a Track & Trend service. TF3 are responsible for installing, maintaining and de‐installing patient equipment in the home. Patient takes their vital signs daily, these are transmitted to the TF3 Triage Manager System – patients breeching parameters are intervened with remotely by triage staff using on‐the‐day telephone interventions and where appropriate the patient’s clinician is alerted. Changes are picked up and appropriate clinical interventions are delivered to minimise exacerbations and associated unplanned use of primary and secondary care services. There is also a patient portal that allows patients to access their vital signs and track their own progress. The contract enables additional services such as Telecare and a knowledge‐based system that uses voice‐recognition to interpret patient‐reported vital sign data via a telephone to be provided.

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John Farrell Department of Health, Social Services and Public Safety

Public authorit

y

B. The Southern Health and Social Care Trust (SHSCT) and the Southern LCG propose to pilot the development of an integrated care partnership focusing on elderly care (patients over 75 years of age), 20,000 users in total. The proposed model would allow multidisciplinary health and care professionals to collaborate, undertaking unscheduled elderly care planning assisted by a common electronic care record. The four essential elements to this activity would include: • risk stratification of the population of patients, which would be overseen by multidisciplinary groups; • integrated patient care planning through the use of an Electronic Care Record (ECR), viewable from multiple settings by GPs, Pharmacists, community nurses, allied health professionals (AHPs), hospital specialists and social workers; • clinical and social care information sharing, through the use of the ECR and multidisciplinary group case conferences; and • evaluation of performance through clinician‐clinician feedback and challenge. Remote telemonitoring and mobile health (MHealth) devices would also be utilised as a mechanism for clinicians to access both real time clinical data and information from the patient’s clinical record, enabling independent living and aiding patients to be involved in their own personal health management. This will help raise the awareness of patients and the elderly population to the benefits of integrated care.

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Magdalene Rosenmoller IESE Business School

Research/academ

ia

IESE Business School is a graduate business school with campuses in Barcelona, Madrid, New York City and teaching facilities in Munich and Sao Paulo, offers MBA programmes and in‐company/open enrolment executive education. IESE is dedicated to state‐of‐the‐art research in all areas of management. In 2012 CRHIM (Center for Research in Health Innovation Management) was founded as a centre of reference and excellence in research into innovation management in healthcare, fostering exchange of expertise, knowledge and experience in the field. IESE has been successfully implementing a series of health related FP6/7 projects, such as Europe for Patients. Most recently it has been awarded the INTEGRATE project on “Benchmarking Integrated Care for Better Management of Chronic and Age‐related Conditions in Europe”; collaborating with some of the most innovative university hospitals and others, including IFIC (International Foundation of Integrated Care).

INTEGRATE aims at gaining valuable insights into integrated care. It will look into best practices of integrated care that have a proven impact in terms of positive patient care experiences; care outcomes and cost‐effectiveness. The key aim is to define what constitutes good quality integrated care provision. By studying real case studies considered to be examples of interesting integrated approaches to medical care and a defined set of horizontal issues across different European health systems, we will identify generic success factors of care integration, taking into account context dependency. The results will be contrasted with international evidence and feed into operational and policy recommendations. INTEGRATE brings together a multi‐disciplinary team with extensive knowledge of the challenges involved in promoting integrated care, drawing on financial, regulatory, human resources, technological, and managerial perspectives, covering very different European settings, including a new Member State, building on existing collaborative relationships.such as IFIC (International Foundation of Integrated Care). INTEGRATE will impact on European health policies by providing managerial and policy recommendations, based on evidence from successful integrated care experiences, with the aim to support health providers and Member States in in better organising health care and systems.

Alice Morsboel Region North Denmark

Health provider

The Region's main task is the improvement of North Denmark health care and is also responsible for regional development and specialized task in the social shpere for children and adults. Health an Consistency is a newly established office in charge of following areas: * Health Agreements with municipalities ‐ including the Chronic Disease

A. Health Profile Study which describes health, morbidity and job satisfaction in the North Denmark population. Knowlegde of a popolations' s health and wellbeing is an important foundation in any effort to provide the best possible health care and meet the needs of the population. Regions, through their access to various health databases and registeres have a very deep

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agreements * The Region's public health responsibilities ‐ including the Health Profiles * Welfare technology ‐ including TeleCare North. Our vision is: For the citizens Region North Denamrk is a good place to be a patient because of our consistency in the health care system and very close relations and coordination between region and municipalities.

knowledge of the population and it's use of various health care options. These records unfortunately do not certain knowledge about public welfare, health habits, the experiences of local communities, their social relations ect. Such knowledge can be obtained only by asking the citizens themselves. The North Denamrk Region therefore implements a health survey "How are you" every fourth year. This study describes the North Denmark poulation's health, morbidity and the job satisfaction. The study is a part of a national survey which is based on 52 identical core questions investigating self‐rated health and well‐being, morbidity, lifestyle and motivation for change of lifestyle. In addition to 52 core questions, the health profile of North Denamrk includes qustions about peple's social capital, mutual trust, confidence and attitudes regarding community framework and opportunities ‐ including participation in community activities. The study is based on wide and spatially health concept, which was developed in an Interreg IIIB project as the Region participated in the 2006‐2008.


Health provider

B. This is health agreements between Region North Denmark and the 11 municipalities in the region ‐ including agreements on the efforts and treatment of people with chronic diseases. Region North Denmark has, through the compulsory health agreement within health prevention and promotion, entered a framework that defines a strategy for action for people with chronic diseases, to ensure early detection, self‐care and unnecessary aggraviation of the disease. Specifically, it

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was agreed that the current contract period must be agreed to work for people with the following diseases: Cardiovascular disease, Diabetes type 2, COPD, Dementia, Musculoskeletal disorders, Osteoporosis, Allergic Disease, Cancer and palliative care, and people with schizophrenia. The goal is to support healthy ageing, which both increases life expectancy and that patients with chronic diseases can live longer in a good quality of life. The goal is to provide health care through integrated care, which is based on the LEON‐principle ‐ that is the effort must be made at the lowest effective level of care. All the 11 municipalities in North Denmark have joined the firest four diseases. The disesae‐specific health agreements define who is responsible for patient care during the course of treatment ‐ including the GP's role as patient coordinator. For each chronic disease there is a cross‐sectorial forum ‐ for the purpose of ensuring that the work tsaking point in the latest evidence.


Health provider

C. It is an implemetation and demonstration project based on findings from research and experience from ongoing tlehomecare projects working diligently to scale the use of telehmecare patients with Chronic Obstructive Pulmonary Disease (COPD), up to full scale. The goal is that all the COPD‐patients in Region North Denmark (app. 2000 persons) who might benefit from a telehomecare solution have it available ‐ regardless of the municipality, hospital or GP with whom they are assosiated. The project is ultimately patient‐centric, utilizing the resources that exist in the patient's own

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network, and applying them in context and interaction with other resources and arrangements in health care. This ensures the greatest possible health, value and impact of investment. From a quality and patient perspective, telehomecare and an inter‐sectoral planning and organization of patient care, create all together patient empowerment and enhanced quality of life through increased self‐monotoring of the disease. From a socioeconomic perspective, there are savings achieved through fewer days spent in the hospital, fewer readmissions, fewer outpatinet visits, as well as the time saved among health professionals in hospitals and in municipal health care facilities

Joaquin de Santos Novartis Industry ‐ large

Novartis provides innovative healthcare solutions that address the evolving needs of patients and societies. Headquartered in Basel, Switzerland, Novartis offers a diversified portfolio to best meet these needs: innovative medicines, eye care, cost‐saving generic pharmaceuticals, preventive vaccines and diagnostic tools, over‐the‐counter and animal health products. Novartis is the only global company with leading positions in these areas. In 2010, the Group’s continuing operations achieved net sales of USD 50.6 billion, while approximately USD 9.1 billion (USD 8.1 billion excluding impairment and amortization charges) was invested in R&D throughout the Group. Novartis Group companies employ approximately 121,000 full‐time‐equivalent associates and operate in more than 140 countries around the world.

The On‐Health initiative in Spain is composed of two parallel clinical studies. The concept behind these studies is that patients with different severities of COPD require different levels of services to support improved disease management. This type of model also enables best use of health systems resources as the more severe patients at higher risk of exacerbation and hospitalization receive a higher level of care and daily remote monitoring. The studies are intended as proof of concept of Telehealth services in COPD covering all disease stages (GOLD B‐D). On‐Health 1 is focused on more severe patients, i.e. with 2 exacerbations in last 12 months both requiring hospitalization. These patients will receive the full Telehealth service, i.e. hub and telemetric devices in the home enabling them to record daily measurements; this data is then transferred to a database where prediction algorithms enable a clinical data triaging service which flags patients at risk‐enabling a healthcare practitioner to view and act on only the most relevant data. Early interventions based

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on this data will prevent hospitalizations and save costs and optimizing healthcare resource utilization. ON‐Health 2 is focused on less severe patients. They will receive a Telemedicine service which includes, educational materials, sms text reminders and calls from their own nurse. Any intervention decisions based on information gathered from service are made by the patients own Doctor in agreement with Nurse.

Rafael Bengoa Department of Health and Consumer

Affairs of the Basque

Government

Public authorit

y

The Department of Health and Consumer Affairs of the Basque Country is the Public Authority in charge of policy, planning, funding and regulation of health issues. Its main responsibilities are to define health priorities and develop policies to improve the health status of the population. It is the body who governs and funds the public Healthcare provider (Osakidetza) and other organizations in charge of biomedical research and innovation (BIOEF) and health services research in chronicity (KRONIKGUNE). It has launched the regional “A Strategy to Tackle the Challenge of Chronicity” and has involved other government areas, research organizations, public and private regional stakeholders and associations to change healthcare for chronic patients, with focus on prevention and promotion, education and empowerment of patients and ensuring continuity of care; hence promoting the ageing well and the independent living of people, sustainability of the system and industrial development

OBJECTIVES •Improve coordination and continuity between care levels •Enhance patient centered and seamless care •Adapt care level to patient needs •Seek efficiencies locally, avoiding duplications and identifying new ways of delivering services APPROACH Evolve to a proactive care system, with a population focus, based on preventive and longitudinal care logics, pursuing efficiency and coordination between health system and other social resources MAIN PROJECTS •Population stratification according to risk level and definition of “population based local intervention plans” , allocating resources on a proactive way and tailored to the needs of different groups •Health care plans for chronic patients with medium level complexity (COPD, DM 2, heart failure): Definition of shared (primary and specialised care) clinical pathways; new role of specialist advisor; straight contact between different specialists •Care for complex pluripathology frail patients, ensuring continuity and care at the most adequate level: Continuity of care plans, telemedicine projects , identified hospital contact professional ; new nursing roles: continuity, case and link managers; subacute care; social care coordination INSTRUMENTAL PROJECTS •Unified electronical medical record •Multichannel electronic platform (O‐sarean) •E‐prescription •Subacute hospitals •Local integrated organizations network •Redesigned commissioning and funding contracts •Kronikgune

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research centre of chronicity

Ana Laguna University of Alicante

Research/academ

ia

The University of Alicante introduces a very important potential for the socio‐economic development which is a fourth province in total GDP of Spain. Fifty degrees , more than seventy University departments and units and research groups in areas of social sciences and law, experimental, technology, humanities, education and health sciences, five University research institutes are planning a research activity of the most prestigious in the country. Our University is the first company in the province of Alicante with more 2,000 workers, and a budget about 199.698.129,00 €.. Research in health sciences is now a16% of the scientific production of the UA. The scientific production of School places the faculty in a prominent place among the centers of the UA. By Meanwhile, teachers have captured over the past 5 years almost million euros in research grants and contracts.

Through specialists nursing en communitary management, coordinate different social and health servicies to give response to new demands of chronic patients and families.

Dafydd Pugh CORAL Other

CORAL's is composed by regions from nine member states, working together to build a community of leading Care Sector representatives. The goal is to provide an open platform for knowledge exchange on assisted living, streamlined access to possible project partners and to coordinate joint initiatives and interests to enhance knowledge and

CORAL – IC will carry out mapping, clustering and mutual learning initiatives on chronic condition management and integrated care. The mapping initiatives will include: • An annual CORAL roadmap on the deployment of remote management of chronic diseases and on integrated care programmes. • The database of stakeholders within CORAL member regions involved in remote management of chronic diseases and on integrated care

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implemented integrated solutions. To do this, CORAL facilitates dialogue, interaction and partnership within its community, through a virtual and static knowledge hub. Here, partners can share experiences, introduce best practices and define policy gaps and innovative solutions. As an integrated network, partners mobilize their collective resources to facilitate the implementation of innovative solutions to common barriers facing the Care sector in their regions, and Europe as a whole. CORAL also works externally, sharing knowledge and learned experiences with non‐CORAL members through conferences, EC sponsored initiatives and workshops.

programmes. • The mapping of organizational models in use and under development in CORAL member regions for integrated care. This includes sharing evidence on outcomes. These mapping initiatives will be used to • Compare and contrast CORAL regional situations to identify the state of the art in remote management of chronic diseases and in integrated care • Identify coalitions of interest for best practice exchange and further joint initiatives such as peer learning and project development • Supporting mutual learning workshops and inter‐regional coaching through existing CORAL initiated activities, such as the CASA Project The CORAL IC Commitment does not supersede the more specific and direct individual commitments made by several CORAL members for actions that can be delivered within their own regions. Instead, CORAL IC dovetails with these commitments by providing CORAL members the possibility to benchmark progress against other CORAL members and learn from each other. These are essential activities of European added‐value.

María Teresa

Arredondo Waldmeyer

Life Supporting Technologies – Universidad Politecnica de

Madrid

Research/academ

ia

LifeSTech group is part of the Universidad Politecnica de Madrid one of the largest universities in Europe, which conducts leading technological research in multiple fields. LifeSTech activities are devoted to the design, development and evaluation of ICT based services and applications, for the creation and promotion of new ideas, methods and technological solutions throughout the value chain of different organizations to improve the quality of life of the citizens in the scope of e‐health and e‐inclusion. The main group skills include consultancy, design, development and evaluation of ICT, Ambient

This joint initiative proposes to share expertise and provide consultancy services for setting up and executing clinical trials for chronic disease management. The partners that constitute this joint initiative are part of HeartCycle project (FP7) which is currently running two pilots that are proving the effectiveness of innovative tele‐monitoring solutions for heart failure monitoring and coronary artery disease rehabilitation with more than 350 patients in 5 different locations of 3 EU countries (United Kingdom, Germany, Spain). These clinical studies are testing a set of advanced solutions based on the use of innovative tools and applications, tele‐monitoring services, personalized treatment, tailored care plans, and education and motivation strategies. We

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Intelligence, Technological Architecture, Business Process Engineering, and System Development and Integration which at the end contribute to provide personal health services and applications to improve wellbeing. The aim is to build products and services that are developed with the focus on the users and their goals, using design for all principles and user‐centered design methodologies.

propose to share the obtained experience in establishing and setting up these pilots within the European community in order to help other initiatives to replicate them or setting up similar ones. Additionally, based on our knowledge in the field and the experience for the implantation of the health maintenance concept ‐ increasingly accepted and adopted within the cardiology society‐, we offer to collaborate in the definition of a future model that offers integrated care to elderly people suffering a chronic disease condition in Europe. The final goal will be the definition of a common work plan for the implementation of this model, and its adoption at different levels (local, regional, national, international).

Beatriz Alejo Servicios de Teleasistencia

S.A. (ST)

Other

The company’s core business is to offer Telecare services to the elderly, the handicapped and chronically ill patients. We provide telecare to both private clients and to those who take part in programmes that are run by Government Agencies. Our Call Centres are staffed with professional teleoperators who are prepared to deal with any emergenc. Our team of Social Workers visits and keeps track of the development of our clients. The Emergency Mobil Units which are dispatched to attend to emergencies are fully trained to resolve the problems. Additionally, we offer specific services for Alzheimer patients and persons with cognitive changes and other dementias. The service consists of permanent tracking in and out of the house through a device which permits GPS and GSM positioning and which is connected to our Call Centre. Our Call Centre and Social Workers also

Our principal objective is to evaluate the impact that a full‐service package, combining the Telecare model with tele‐monitoring, may have in the number of times chronic patients is a admitted into a hospital and if there is a perceived improvement in the quality of life for the user, the care giver and the medical team. The study will have special emphasis on elderly people. We will begin the project in Zaragoza, but our intention is to then export the study to other parts of Spain.

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attend to women who are victims of violence. The goal is to offer peace of mind, security, support and protection to the women

JOSEP ROCA Hospital Clinic ‐ IDIBAPS

Health provider

HCPB (www.hospitalclinic.org) is a tertiary care hospital with a high international profile which developed during the last decade an ambitious care coordination program with ICT support for chronic patient management in a sector of 540000 h. IDIBAPS (www.idibaps.org) is a top research centre formed by the Catalan Ministry of Economy and Knowledge, University of Barcelona, HCPB and others. During the last 25 years its mission has been to encourage translational research, innovation and technological progress in the field of biomedicine. HCPB‐IDIBAPS collaborate with TICSALUT in the deployment of the chronic care program in Catalonia, and they are leading several EU projects involving deployment of ICT for health and Systems Medicine approaches for patient stratification. Some of these working lines led to the creation of Linkcare HS (workshop.nexeshealth.eu) a spin‐off promoting an open ICT platform for chronic care management and knowledge sharing with an open business approach

Since early 2000s, we have assessed innovative Integrated Care Services (ICS) for chronic patients and developing ICT to support organizational interoperability across tiers of care. By early 2006, we initiated local deployment of ICS. The maturity of this deployment effort was reached during NEXES (CIP‐ICT‐PSP‐2007‐225025, 2008‐12) using Linkcare as an open Health Information Sharing platform. In Nexes, the full potential of ICT as a facilitator of the deployment of highly efficient ICS has been released by fully supporting and assessing innovative ICS workflows that aim at transferring complexity from hospital to primary care and to patient home. The current proposal aims at contributing to large scale adoption initiatives at EU level through specific areas of action wherein we have gained expertise: Firstly, by sharing the practicalities of the ICS deployed in NEXES with other European Regions. Maturity in the analysis of the economic outcomes and successful business models of integrated care is a knowledge that we would like to offer to other partners looking for coordinates on deployment and sustainability of these services. Secondly, by further developing an ICT architecture to face the challenges posed by the interoperability between bioscience research and clinical information; and, also, to respond to the interest to take

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advantage of the continuum of care to gain further understanding on chronicity and co‐morbid conditions using a Systems Medicine approach

Simonetta Scalvini IRCCS, Salvatore Maugeri Foundatio

Health provider

FSM, founded in 1965 by Prof.Maugeri as a Work and Rehabilitation Clinic, operates in Rehabilitation Medicine, with the aim of helping people recover remaining functional abilities and quality of life, through highly specialist rehabilitation services. It has been a Scientific Institute of Care and Recovery since 1969, and is present throughout Italy with a network of Institutes and Prevention Centres. Clinic activities, focused on chronic patients, are directed towards the diagnosis and cure of patients with neuromotor, cardiac and respiratory impairments, and polisystemic chronic disabling diseases. Welfare activities support researches in the compilation of diagnostic protocols, guidelines and rehabilitation protocols with a translational approach in the field of complex pathologies, with a high absorption of resources. Research activity involves more than 50 Scientific Laboratories and develops along lines and themes that are both indirect and specific to this complex activity.

The Telehomecare programme for patient with multiple chronic diseases is a multidisciplinary care approach referring to biological signals monitoring and medical/nursing intervention made over the telephone. The care model provided 24/24 h assistance, 365 days/year. Briefly, a nurse‐tutor (NT) followed‐up the enrolled patients for 6 months managing the weekly contacts with them, mainly through scheduled appointments (from Monday to Friday from 8:30 am to 4:00 pm). Occasional appointments could also be required by patients and performed by a nurse on duty in case of symptoms, signs of possible instabilization of the disease or any doubt about therapy occurred in urgency during the day, nights or on week‐ends. The patients received some portable device (1‐lead ECG, pulse oxymeter etc…) depending from their diseases; the biological signals are transferred during each call by a fixed or mobile telephone to a receiving centre, where a nurse or a doctor was always available for consultation. All the patient’s data are present on an electronic health record present on a web platform. Educational Video, games for brain training, CD‐Rom with callisthenic exercise for physiokinesis therapy (FKT) and a notebook with mobile broadband which allows point‐multipoint video and audio transmissions simultaneously were provided. Videoconference rehabilitation sessions were provided every morning and afternoon between patients, nurses and therapists.

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Anna Sachinopoulou

Centre for Health and Technology, University of

Oulu

Other

The Centre for Health and Technology (CHT) is a regional research‐ and business ‐driven innovation centre. The founding partners of CHT represent six stakeholders on research (VTT, Univ. of Oulu, Oulu Univ. of Applied Sciences), Public sector (City of Oulu, Oulu University Hospital ) and Private sector. Main focus of CHT is to promote the research, development and innovation on the individualized healthcare. CHT is enhancing the cooperation at national and international level. CHT is a partner of European Connected Health Alliance. The building blocks to make Oulu a citizen‐centered ecosystem of health are: 1. Oulu’s unique concept of cooperation: Oulu Innovation Alliance‐ cooperation agreement for co‐creation and co‐invest on the research and development on certain focus areas, like the individualized healthcare (CHT). 2. Remarkable development programs which aim at most advanced social and health services products and innovations to promote the well‐being and independent living.

The present coalition includes members that are cooperating towards the implementation and deployment of integrated care as it is defined in the Operational Plan of the EIP‐AHA. The target is twofold. To comply to the New Act of Finland that demands cooperation and integration between primary care and specialised healthcare (public and private sector; integrated operations over organization interfaces) , as well as to become efficient by using new integrated care models, technology and by facilitating and empowering the citizens to use on‐line services in follow‐up and rehabilitation phases. To this purpose the present coalition would like to commit to cooperation with all necessary stakeholders, to engage professionals to integrated care programmes (education and training), to identify and develop integrated care models that will be reproduced in other regions (in Finland and in EU) and to produce evidenced based evaluation (business and financial) methods for integrated care.

Theodore Vontetsianos e‐Health Unit, "Sotiria"

Hospital, 1st RHA of Attica

Health provider

The 1st Regional Health Authority (RHA) of Attica is one of the 7 respective Authorities in Greece, responsible for the service of 3.5 million people in the wide area of Athens, coordinating 25 major hospitals. Since 2000, an ICT supported, elderly and chronic patients’ care management program has been established in the e‐Health Unit of “Sotiria” Hospital, one of the largest ones, on behalf of the whole Authority. The pilot program has resulted in a decrease of patients’ in hospital stays by more than

Since 2010 our Unit is trying to move from the pilot phase to a deployment one, providing ICT supported integrate care services on a regular basis of the 1st RHA of Attica everyday clinical practice. In this endeavor a structured program has been recently established, funded by national structural funds (National Strategic Reference Framework ‐ESPA 2007 – 2013, Digital Plan, Ministry of Development and Health). The program addresses the care management and remote monitoring needs of elderly and chronic patients served by the Hospitals and Centers of the Health Authority. The total target population consisted of more

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50%, significant improvement of their quality of life, health and social care system decongestion and significant cost savings. The e‐Health Unit has been accredited with the label of best practices from the “Good e‐Health” and “ePractice.eu” EU organizations. It has also been honored by EC with the winning prize in the “e‐Inclusion Awards 2008”, as well as with invitations in several high level events as a good practice case.

than 400.000 chronic patients (COPD, CHF, Diabetes mellitus etc.) in the region of Attica, as well as of more than 80.000 ones, living in remote and isolated islands of the Aegean Sea. The vast majority of them are socially disadvantaged elderly of low level of education and income with poor control of their condition, representing the main burden to the health and social care system. The program anticipates the innovative usage of cutting edge technologies, involvement of all the needed medical and other allied personnel, building of solid networks with the relevant stakeholders (insurers, social care providers, patients’ associations, academics, industries, SMEs etc.), as well as the indicated organizational, administrative and financial innovations which are needed. Its official launch is foreseen within 2012.

Dagmar PD Dr. med. habil. Pöthig

Europäische Vereinigung für Vitalität und Aktives Altern eVAA e.V.

Advocacy

organisations

eVAA (European Association for Vitality and Active Aging) is a nonprofit organization that sees itself as a manager of a free and independent platform of knowledge, expertise and contacts for the topic of health resources, quality of life and aging.The main task of the eVAA is the catalyst of interdisciplinary and multiprofessional process innovations in the health care and social system, education market and labor market institutions and in cooperation with shareholder from politics, business, sciences, education and media. We follow an epistemiological strategic line. Under the scientific roof of Gerontology we bring into action a powerful and experienced network of experts from medicine, nursing, health sciences and biology. Furthermore international innovative gerontological instruments are available ‐ such as evidence‐based and ICF‐

Capacity building and transferability of successful integrated cure and care systems based on innovative structures, tools, processes and services. The approach shifts the supply of a reactive to a preventive, proactive and patient‐centered cure and care, up from an institutional one based jointly and home care, and they bring in benefits in terms of reducing avoidable/ unnecessary hospital stays, more sustainable and optimal use of resources and more effective cure and care throughout the systems. Ultimately, this will bring benefits for consumers and bring the concept of patients as co‐producers of health as an integral part of the whole system.

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orientated AGE and HEALTH Monitoring Systems to determine the Biopsychosocial Status and the Biofunctional Age of a person and of defined groups.

Enrico Piras Fondazione Bruno Kessler

(FBK)

Research/academ

ia

Fondazione Bruno Kessler (FBK), is a private non‐profit research center. Established by the government of Autonomous Province of Trento (Italy), FBK conducts research in the areas of Information Technology, Materials and Microsystems, Italo‐Germanic Historical Studies and Religious Sciences. Other activities include studies on networking and telecommunications with a particular focus on government and welfare. FBK employs 350 researchers, graduates, post‐doc students, and visiting professors. FBK is organized in 6 research centres, 7 laboratories, and a number of field projects active across the Province’s territory. FBK has generated 14 spin‐offs, start‐ups and joint‐ventures. Throughout 50 years FBK has developed a broad network of domestic and international alliances and strategic partnerships, hosting and attending international congresses, conferences and symposia, publishing hundreds of papers and innovative ideas earning FBK a respectable international standig

Since 2008 FBK has activated a Living Lab to design and implement TreC (www.trec.trentinosalute.net), a Personal Health Record aimed at providing the whole population of the Province with access to the services of local healthcare authority. TreC, tested by approx. 800 citizens, will be released to the general public by 2012. On top of this infrastructures, in 2011 we designed two dedicated applications for chronic condition (youth asthma, type 1 diabetes) and two pilot studies were activated to test new forms of personal health information management and sharing among patients, relatives and doctors. In 2012 we will start a pilot study on shared monitoring of elderly with type II diabetes. Building on on‐going experiences and making use of the same digital and institutional infrastructure we will adopt a Living Lab approach and participatory design techniques to involve the key actors (elderly patients, relatives, care workers, healthcare operators) in the early stage of the process to co‐design, refine, test and assess in real life conditions the technologies, the organizational impact and clinical benefits. TreC is designed to support the network of formal/informal care people build around their needs. We plan to design an ecosystem of different diabetes information management mobile and web applications to be used by patients, relatives, care worker and healthcare

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personnel to allow all the shared monitoring of elderly.

Marten Munneke Radboud University Nijmegen

Medical Centre

Research/academ

ia

Radboud University Nijmegen Medical Center (RUNMC) integrates the Academic Hospital and the Medical Faculty of Radboud University (RU). RUNMC and RU are governed by the Foundation Catholic University. Other RU faculties and institutes relevant in the area of active and healthy ageing (AHA) are Nijmegen Centre for Molecular Life Sciences, Nijmegen Institute for Evidence‐Based Practice, the Nijmegen School of Management, the Faculty of Science and the Donders Institute for Brain, Cognition & Behaviour, proudly hosting the Max Planck Institute for Psycholinguistics. The 3 core tasks of RUNMC are patientcare, education and research. Patientcare has a local, regional as well as (inter)national scope, with yearly around 150,000 outpatient visits, 30,000 hospitalizations, 45,000 day treatments and 28,000 emergency care visits. Over 3,300 students are registered for Medicine, Dentistry, Biomedical Sciences and Molecular Mechanisms of Disease. In total, close to 10,000 employees work at RUNMC.

Many health professionals are involved in the care of elderly who face multi‐morbidity. The quality of care provided by these professionals is often insufficient, due to a lack of expertise and a challenging collaboration. To address these demands ParkinsonNet was successfully introduced in the Netherlands for delivering care in Parkinson’s Disease (PD). ParkinsonNet consists of regional networks of primary and secondary care for PD, supported by online tools to enhance information exchange and communication among the network members. In the adherence area of a general hospital, ParkinsonNet aims to select and train allied health professionals to work according to evidence‐based guidelines; boost patient volumes per therapist by stimulating selective referral to ParkinsonNet therapists; and support collaboration between allied health professionals, neurologists, and empowered patients. The netwerk stimulates a patient‐centred, integrated team approach. Current ParkinsonNet networks in the Netherlands are multidisciplinary. Because of feasibility purposes, we started off developing networks for physiotherapy only. Physiotherapy is the most widely used allied health intervention in PD. The completion of the European physiotherapy guideline in PD in 2012 creates the opportunity to extend ParkinsonNet, starting off with physiotherapy, to other

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European countries. We plan to implement the guideline throughout Europe by means of regional networks, based on the ParkinsonNet model.

Roberta Centonze Fondazione Democenter‐

Sipe

Research/academ

ia

Democenter is an integrated care system actor, acknowledged by the Emilia‐Romagna Region as coordinator of the BIOMEDICAL DISTRICT of Mirandola, and responsible for the Quality Center Network (QCN). It establishes cooperation between health enterprises & health related institutions to transfer know‐how from industrial sector into clinical phases, and patients' daily life. Democenter identifies funding opportunities, appropriate partnership, technical solutions for undertaking organisational and administrative innovations, new business models, patient‐ specific care plans, telehealth&telecare systems and interoperable ICT systems, business development projects, which it monitors and supervises. Democenter is a no profit organisation associating Public Administrations, Research Institutions, Enterprise Associations & more than 60 Industrial Companies. At the EU level, it has started networking activity on chronic diseases issues, taking part to initiatives and project proposals.

Thanks to its network of partners, gathering Enterprises, Health care providers and advocacy organizations, Democenter acts as a collector of needs, ideas and knowledge rising from different fields. It supports the development of new projects dealing with chronic diseases, with a particular focus on dialysis treatment and pain management. The interest in dialysis topic spans from the new materials of devices and disposables to processes of cure, to telemedicine and integrated care systems. Democenter is strictly connected with the biomedical district of Mirandola, the most important BIOMED site in Europe. On the other hand, the attention for pain management stems from the strict collaboration with ISAL foundation, promoting research and therapy for chronic pain relief. Democenter commits itself at representing a bundle of stakeholders from a privileged perspective actively integrating with the ASSR. It is expected to take part to all the meeting initiatives for B3 action. Democenter as technology transfer centre, is committed to promoting research project, demonstration programs and specialized conferences, and providing managerial and technical support to its partners, fitting with the integrated care concept that concerns collaboration among all parties within care systems. It contributes to laws & norms progress and harmonization across EU.

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Camille Bullot Assembly of European

Regions (AER)

Other

AER is the largest independent interregional network in Europe, with over 250 regions from 34 European countries. AER is a forum for regional politicians to engage in interregional co‐operation and to voice regional interests on the European stage. AER is active in all policy areas where regions have competences. The AER Social Policy and Public Health Committee leads AER’s work in sustainable health and social care with the following policy priorities for the period 2012‐2013: Active and healthy ageing; Innovation in health and social services; Building inclusive societies (including a network on equal opportunities for people with disabilities) The AER e‐he@lth network supports regions to embrace innovation and ICT in health and social care. We adopt a multi‐stakeholder approach and help regions work with their local stakeholders (industry, SMEs, universities, patient and health professional associations) to further develop and successfully deploy ICT for health and social care.

AER will support capacity‐building in the regions in order to support regions to implement innovative integrated care models. A series of targeted workshops will be organised in different parts of Europe, with at least 1 workshop organised per year. These workshops will be organised in the local language and will respond to the needs and priorities that the regions identify themselves. The workshops will target regional decision‐makers and officers, but also local stakeholders (SMEs, patients and professional associations, research). In terms of structure, they will map the current situation, present successful examples of e‐health and integrated care that have been implemented in other regions and identify possible funding sources for the adaptation and implementation of these models. AER is currently awaiting the evaluation of 2 project proposals. One will allow us to organise additional workshops and further deploy integrated care models. The other allows AER to work in a wider community of stakeholders and thus bring additional knowledge and expertise to the regions. AER will also launch an information campaign for regions on how to invest EU Cohesion Policy funds in health. The aim of this campaign will be to encourage regions to ensure that health‐related investment priorities are included in the Operation Plans that will soon be negotiated and that will list spending priorities for the future Cohesion Policy, 2014+.

Javier Laucirica IK4 Research Alliance

Research/academ

ia

We are a private and independent technological Alliance, a benchmark in the Basque System of Innovation as well as in the European technological context, made up of the following technology centres AZTERLAN, CEIT, CIDETEC, GAIKER, IDEKO, IKERLAN, LORTEK, TEKNIKER and VICOMTech. Since our creation in 2005, we have become an Alliance of

Strong international evolution calls for rapid services change and quick adaptation. Current collaborative actions within Ageing are sometimes lacking of a full commitment on the full stakeholder chain and thus, outcomes not always produce real impact on the society. This model claims for new collaborative paradigms. ATTICA proposes the commitment of regional, national and international players involved within the Ageing domain, so a

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superlative technical centres, brought together with the objective of bringing value to society and of reaching a critical mass in tune with research which is applied to and aimed at the industrial framework, in the interests of contributing towards providing that framework with the tools which will allow it to increase its competitiveness. Our eight technological and scientific units bring together the entire R+D+i resources of the members:biotechnology, micro and nano technologies, environmental technology and recycling,energy, industrial management and production, mechatronics, materials and processes,and information and communications technologies

real transnational collaborative ecosystem is set‐up. IK4 is boosting this initiative from their strategic position as key player bridging public health entities and organizations together with the industrial stakeholders; this position provides an exceptional ability to trace a common work plan along all the participants.

Stefano Cencetti Agenzia sanitaria e sociale

regionale

Public authorit

y

The Regional Health and Social Care Agency (ASSR) has organizational and operational autonomy and provides a technical and regulatory support to the Regional Health Service (SSR), and to the integrated system of interventions and social services. In particular ASSR mission is to implement the SSR according to: • Ensure technical quality requirements, • Provide the implementation of the Regional Health Plan by the Local Health Authorities, • Provide a clinical governance of the Regional Health Service and participation of workers; • Integrate all healthcare and social services and facilities, • Ensure transparency towards the citizens, users and their representatives, organizing their participation in the evaluation of services, • Integrate care, research and training.

The Emilia‐Romagna healthcare system is aware that in order to be more sustainable from a financial point of view, and thus, more targeted on the seniors’ precise exigencies, the welfare state needed to undergo substantial variations through the re‐organization of assistential pathways utilization of new technologies, provided that these tools are adequately supported and, in return, support the decisional and organizational processes. The aim of our commitment is to overcome the senior people's limitations in ADLs, with an integration of social and healthcare services. Given the characteristic of such population, the main action will consist in building a network for remote monitoring tools (for heart failure, diabetes, COPD, fall prevention, cognitive and functional decline), with the purpose of renewing the assistential pathway. The action will develop a collaborative model involving all social and healthcare‐related workers (Local Health Authorities‐LHAs, social services, third

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bodies such as call centers and service coordination structures), and with a special emphasis on informal carers (family support, substitutive figures).

Francesco Bucci CSI‐Piemonte (Consortium for Information Systems)

Other

CSI‐Piemonte is Public Consortium for Information Systems. It was founded by the Piedmont Region, the University of Turin and the Polytechnic of Turin in 1977 with the aim of promoting the modernization of local administration by using the most advanced information and ICT‐based tools to create information services and systems. Nowadays, it counts 91 consortium members, about 1200 employees, 6 office locations in Piedmont, 1 office in Albania and an annual turnover of 156 million € (year 2010). Thanks to the consortium, Piedmont has become an integrated administration “system”, able to face the e‐government challenge, simplify administrative processes and meet the expectations of citizens and companies alike. Well‐known both at national and international level, CSI‐Piemonte represents a unique player in terms of it being a ‘public’ consortium organized along ‘private’ lines. Nowadays, it is one of the largest Italian ICT operators in the public sector.

TelMed VCO is a telemedicine project implemented in the Area Verbano Cusio Ossola (VCO) in Piedmont (Italy). It is a monitoring and assistance service “on‐going” since 2008 for patients with chronic diseases or with stable care needs, remotely assisted at home. It permits to virtually connect experts, nurses, health operators etc. and it addresses different pathologies by integrating hospital, specialists and territory care services. The patients’ monitoring follows the protocols for their specific illness, and it allows to give indications about how to proceed in the care. Patients can be directly contacted by their practitioners using videoconference. The telemedicine service provides a proved better health‐care quality to people living in VCO mountain territory and it is focused on the most common pathologies associated to elderly: hyperthension, diabetes and cardiopathy. Since 2008 the project TelMed VCO has been sponsored yearly by the local Authorities (Regione Piemonte) despite the current scarcity of public financing resources, our commitment for 2012‐13 is to maintain actively the service and to extend the monitoring field towards other pathologies and to other Piedmont’s Areas.

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Josep Redón University of Valencia. (UVEG)

Research/academ

ia

The University of Valencia (UVEG), founded in 1499, with over 3000 researchers organized in 92 departments, 20 institutes and other research units dedicated to social, biomedical, human, experimental and formal sciences, is one of the top public research organizations in Spain. There is a traditional relationship between the Hospital Clínico Universitario and the Faculty of Medicine, regularized through the Hospital´s Biomedical Research Foundation (INCLIVA), as research groups of excellence in biomedicine belong to both institutions. Polibienestar, research institute of the University, develops interdisciplinary research on both basic and applied economic, social, political and technical welfare systems. It advises the Administration and the market in the design, planning and implementation of resources and social welfare policies for chronic ill or dependent people. UVEG, part of the Spanish Network of Aging and Frailty, has developed several FP European projects on this topic.

Frailty, whose key elements include chronic malnutrition, sarcopenia, decreased strength, and cognitive decline, can be promoted or triggered by internal or external factors, like illness, falls, stress, etc. We aim to assess frailty in hospitalized aged patients, by analysing physical dependence, cognitive impairment and comorbidity, in order to provide specific support (general and disease oriented) to reduce the risk of re‐hospitalization and to improve quality of life and survival, determining a vulnerability profile for aged patients, focusing on acute coronary syndrome (ACS), and establishing a relationship with prognosis in terms of mortality, reinfarction, or re‐hospitalization. Actions to support interventions to reduce frailty include creating new care models for ischemic heart disease (IHD) in aged patients, in which patients have a proactive role and professionals have the most advanced technologies to support decision making, personalize treatments, and guarantee a more continuing care, promoting health, risk management and prevention of diseases. More specifically: • Develop algorithms and complex models of decision making applied to IDH in aged patients including prognosis according to their vulnerability profile. • Develop proactive rehabilitation strategies for aged patients with IHD including social factors, allowing professionals to customize care, increasing quality and effectiveness, and patients to improve chances of recovery and wellbeing

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Peter Simonsen Region Syddanmark (Region of Southern Denmark)

Public authorit

y

The Region of Southern Denmark (RSD) has a population of 1.19 million. The region’s main tasks include healthcare and regional development; it has the responsibility for running the region’s five hospital units and for developing regional economic development plans. RSD has become a centre for innovation in ICT based health solutions, supported by a strong infrastructure. The infrastructure is based on programmes for continuity of care and health agreements between the different parties in the system. The region makes continuing investments in telemedicine and new eHealth projects; and cooperate closely with regional, national, as well as international partners. The aim is to improve the quality of life for older people and chronic patients and invest in public‐private partnerships in order to develop innovative services and technological solutions to the benefit of patients and citizens as well as regional businesses.

RSD will join the EIP‐AHA from two angles; One is from a regional development perspective, where focus is economic growth in the Region and the other is from a health and social care perspective, supplying services for all citizens. The effort for the elderly in RSD takes it starting point from a vision underpinned by several strategies. One strategy ensures the improved communication and integrated care between health and social services and other services necessary to lead a healthy and active life. There are also joint actions, which will be carried out. Among these are actions to create joint development projects regarding digital communication and ambient assisted living technologies (AAL) that will support an effective and cost‐conscious provision of services. In addition, RSD will support and roll‐out ICT services such as telemedicine, eHealth and remote monitoring. Among these are Patient@Home and the Shared Care Portal in addition to several EU projects. In order to foster regional development, there is a regional business strategy and action plan, with a focus on smart specialisation and with health and social innovation as one of three prioritised areas of business excellence. This area not only represents an exceptional potential for growth and entrepreneurship but also has the potential to turn societal challenges into future business opportunities.

Anders Carlsson New Tools for Health

Other

New Tools for Health is a regional “quadruple helix” cluster initiative established in 2005 as a membership association. The main actors with permanent board representation are Linköping University (main research actor in the region), the County Council (main care provider), the main municipalities (Norrköping and Linköping, which are social care providers as well as regional growth

The New Tools for Health organisation is the East Sweden region's front‐runner in terms of innovative research and innovation for future distributed care, self‐care and independence in connection with chronic diseases. The initiative is base funded by Vinnova, The Swedish Governmental Agency for Innovation Systems, during the ten year period 2005‐2014, and planning has now started for the period after 2014. Core activities are innovation expert support and funding in early

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promoters) plus elected representatives from the 50 company members and end‐user organisations. It is base funded by VINNOVA, The Swedish Governmental Agency for Innovation Systems through their major regional growth/innovation programme Vinnväxt and by the regional organisations as above. The core activities are innovation stimulation and support. A major focus area is 'independence for people with chronic diseases", especially heart failure and diabetes, by means of mobile ICT. A main asset is a test bed in real life residential environment with 10 000 potential end‐users and 1000 people above 80 y/o.

innovation stages, through the entire development process, including pre‐commercial pilot tests and commercialisation and deployment. Thanks to the involvement of the major care providers in the region as well as end‐users, demand‐based expert support and great pilot test opportunities are provided. In addition, research‐based expertise in the areas of health technology assessment (HTA), health economy, ethical issues (specific competence on telemedicine ethics) and social oriented research on technology use among elderly (National Institute for the Studies of Ageing and Later life, NISAL). All these resources are employed in the certain focus on mobile ICT innovation in order to achieve increased independence among people with the chronical diseases congestive heart failure and diabetes, with the goal to deploy the solutions beyond pilot‐scale. In order to succeed in this respect, the initiative cooperates extensively in a European context, of which the membership in the CORAL network is most important.

LEOCADIO RODRIGUEZ MAÑAS

SERMAS‐HOSPITAL

UNIVERSITARIO DE GETAFE

Health provider

The SERVICIO MADRILEÑO DE SALUD (SERMAS) is the structure that integrates all the 31 public hospitals, including the Hospital Universitario de Getafe, and every public health service of the Madrid Regional Health System. SERMAS is the project coordinator, and delegates’ authority to Hospital’s General Director to manage research projects. The “Fundación para la Investigación Biomédica del Hospital de Getafe” is the third party linked to Hospital Universitario de Getafe in order to manage the administrative tasks of the Hospital in regard with research activities, as well as carrying out certain research activities. One of the official

Diabetes is one of the most important chronic diseases associated to the development of functional and cognitive impairment and frailty in elderly people. However there is not well‐defined models for care these patients and few of them have been tested. Diabetes patients show many peculiarities doing them very different to the other patients with diabetes: usual comorbidity, reduced life expectancy to develop long‐term complications of the disease but also to benefit from some benefits of treatment, high probability of secondary effects and usual concomitant frailty or disability. These characteristics raise the necessity of developing and implementing models of care tailored to their needs that would overcome the usual models based on the control of metabolic and vascular problems of the

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research‐lines is ageing, with the main focus in frailty, diabetes and RCTs in older people. We have formal relationships with Primarty care network, social facilities (including nursing homes), University. We lead the Spanish National Network for Research on Ageing and Frailty, embracing 28 outstanding research groups on aging along Spain.

disease to focus on a new "Functional Model" to manage both disability and chronic disease using an interdisciplinary approach to delay the onset of, or reduce likelihood of, frailty and disability. This model would stem from the following principles: Focused on the patient and its functional status/quality of life, bridges cultural/ethnic boundaries, integrates structures and patient education, uses information systems supported by Tele‐Medicine approaches and Internet‐linked clinical support models, provides carer involvement strategies and cost‐effective Diabetes care by well‐motivated and trained healthcare personnel.

Marc Lange EHTEL Other

Founded in 1999, EHTEL (the European Health Telematics Association) is a pan European multi‐stakeholder forum providing a leadership and networking platform for European corporate, institutional and individual actors dedicated to the betterment of healthcare delivery through eHealth. EHTEL serves and convenes a growing membership of more than 50 organisations that come from various viewpoints but united in their interest to make eHealth work. By collecting and distilling their voices through work groups and publications, EHTEL amplifies the constituency for eHealth in the European arena. We also facilitate the sharing of experience with colleagues and representatives across Europe and beyond. The multitude of their backgrounds and interests enable EHTEL, as a neutral forum, to draw a more complete picture of the benefits and challenges of the deployment of ICT in the fields of health and social care, thereby also identifying topics requiring particular attention

In EHTEL views, “Seamless Integration for Personal Health Services” is to be understood as providing ICT service support to improve citizen/patient‐centric collaboration processes between health and social care, between secondary, primary and home care. The ICT‐based services in focus of EHTEL activities include infrastructure services as well as telehealth or Telecare services. With this initiative, EHTEL is renewing its commitment to be a neutral forum to support developping capacities for deploying eHealth services in daily practice and with a particular focus on the developing capacities to deploy ICT services in the field in view to support Seamless Integration for Personal Health Services. The objective of this initiative will be to enable experts and stakeholders sharing and learning from experiences and identifying good practices. This will take the form of ‐ Working Group meetings calling for experts belonging to the same stakeholder group in view to discuss on regular basis topics which are specific to this stakeholder group; ‐Task Force meetings calling for experts from different stakeholder groups in view to discuss a given topic from different perspectives; typically, this type of activity will be funded by an EU funded project EHTEL or

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at EU level. one of our members is part of. The results of these meetings will be used to feed B3 Action Group activities.

Brian O'Connor European Connected

Health Alliance (ECHAlliance)

Industry ‐ SME

ECHAlliance is a not‐for‐profit membership organisation with offices in N.Ireland and Finland. It is an initiative designed to support and promote the wider adoption of healthcare and wellbeing, products, services, applications and innovation. We bring together commercial, academic and healthcare stakeholders, ECHAlliance facilitates focused leadership for the development of ‘Connected Health’ markets and practices across Europe and beyond. The scope includes the economic development of the full range of eHealth, EHR, TeleCare, TeleHealth, Telemonitoring and MHealth sectors. We provide a unique partnership of organisations, companies and government bodies and will assist in the creation of “business” opportunities for our members. Focused on the need to transform Healthcare Delivery, thus enhancing the quality and effectiveness of care; and the need to develop the ‘Connected Health Economy’, thus enabling innovation and sustainable investment in the expansion of healthcare.

Our commitment is to make the integrated care for chronic diseases a top priority. We will connect and work with regional health authorities, business (large & small), patient groups, academia and other stakeholders to deliver specific initiatives for the successful deployment of connected health innovative solutions, to assist those with chronic conditions through large scale deployments of remote monitoring. ECHAlliance, with over 120 member organizations, is working to ‘Deliver Permanent Connected Health Ecosystems’ across European Regions. We believe that collaboration in innovation and breaking down barriers by focusing on specifics provides the opportunity to tackle those key priority issues and deliver timely better care. While understanding that we are in living in a rapidly evolving, highly demanding and challenging healthcare landscape, the healthcare systems worldwide are being confronted with huge challenges to cut costs while improving the delivery of care. We all strive to continue to meet these new challenges by constantly seeking new innovative perspectives, by incorporating new technology and by adapting new efficiencies to provide better service delivery. Innovation, scaled deployments and remote monitoring technologies lie at the heart of the solution. We realise a seismic shift in the way services are currently accessed and delivered needs to become the order of the day.

Christoph Westerteicher Philips Healthcare

Industry ‐ large

Philips Healthcare is part of Royal Philips Electronics of the Netherlands, a diversified Health and Well‐being company, focused on improving people’s lives through meaningful innovations and a world leader in healthcare, lifestyle and lighting. Philips

The joint ACT commitment supports effective implementation of Care Co‐ordination and TeleHealth (CC&TH) services in the routine management of chronic patients in five European regions: 1. Basque Country 2. Catalonia 3. Groningen 4. Lombardia 5. Scotland Focus will be on managing entire groups

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Healthcare is one of the largest home monitoring solution providers in the world, and has over 15 years of experience in International and European TeleHealth. The ACT program (subject of this commitment) will be coordinated by the Philips TeleHealth EU Business located in Böblingen, Germany. The ACT program will be supported on administrative, legal and financial matters by the Philips EuroPartners organization, an internal Philips office dedicated to support all European public funded projects Philips is involved in.

of heart failure, COPD, diabetes, as well as co‐morbid patients, with at least 3,000 patients per region. ACT will look at tailoring CC&TH services and solutions to specific needs at all acuity levels set out in the Kaiser‐Permanente Acuity Pyramid. With the inclusion of Care Co‐ordination, the regions and the healthcare experts will evaluate the integrated delivery of healthcare services between community care, primary care physicians, hospitals, friends and family, and how to organise these to provide optimal care. Chronically ill patients will be managed using the existing healthcare delivery structures within the regions. However, in conjunction with the healthcare providers and an CC&TH expert team, we will investigate how the organisational and structural elements that influence effective deployment of CC&TH are currently being used and how they can be optimised. The results will be compiled in a Cook Book with best practice and recommendations for replication in other regions. The commitment is dependent upon the availability of funding recently applied for under the DG SANCO Health programme, to cover the overhead costs related to its implementation

Justine Westwood NHSScotland, co‐ordinated by

NHS 24

Public authorit

y

Scotland has a population of approximately 5.2 million people, with responsibility for the publicly funded health and social care system devolved to the Scottish Government and delivered by NHSScotland. NHSScotland provides an integrated healthcare system with all hospital and community health services delivered by geographical Health Boards, and has embarked on the integration of health and social care services (provided by Local Authorities) to deliver safe, effective and person

Scottish Government’s 2020 strategic vision for health and care is that everyone should live longer healthier lives at home, or in a homely setting.This is supported by a legal framework of integrated health and social care with a focus on prevention,anticipation and supported self management.Care will be high quality and safe, with a focus on supporting people to return home or to a community environment from hospital as soon as appropriate with minimal risk of readmission. Scotland has already initiated the redesign of integrated care pathways to support staff,individuals,carers and communities to provide a

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centred care. NHSScotland recognises that in order to address the future demographic challenges, appropriate investment in innovative forms of care and support is required. NHS24 is NHSScotland’s national provider of Telehealth and Telecare Services, and manages the Scottish Centre for Telehealth and Telecare, an organisation that supports the development and delivery of evidence based ICT supported healthcare services across Scotland, delivering Scotland’s national Telehealth and Telecare Strategy

more personalised and targeted approach to care delivery, eg The Telecare Development Programme,delivering telecare to 44,000 people and the national telestroke programme implemented in 11 of 14 health boards.Building on these, we are progressing 3 large scale programmes of ICT enabled integrated care over 2012‐15 –Living it Up/DALLAS,SmartCare and United4Health (if succesful). These programmes will build on an electronic record which links out of hours and emergency care for a more preventative and proactive approach,supplemented with telemonitoring tools to support care assessment and community inclusion for frail,older people. Many existing services are already at scale but only partially embedded in mainstream care in some areas.We will share our learning from these programmes and learn from others to embed technology developments in integrated care more effectively

Maria Dolors

Ruiz Morilla Mútua Terrassa Health provider

Mútua Terrassa founded in 1900, has an annual turnover of 240 million € (2010) and is constituted by various operating units: The hospital, associated with the University of Barcelona for education in pre‐ and postgraduate courses, belongs to the Public Hospital Network and has more than 460 beds, 34 departments and received in 2009 more than 450.000 visits; nine primary healthcare centres, offering healthcare services to a potential area of more than 300.000 citizens, had more than 1.5 mio visits in 2009; The insurance company, offering insurance services to more than 60.000 clients; the social healthcare and support services to dependent people with a capacity to host more than 100 residents; and the logistical park, providing services

Our project consists of a platform for the integral management of patients with chronic diseases in primary healthcare, targetting in its initial stage on five highly relavant chronic diseases: diabetes, hypertension, obesity, COPD and heart failure. The aim of the Aprop project is to improve the health and the living quality of the patients with chronic pathologies by means of a telemedicine platform that offers tools to the primary healthcare team for a better integral management of the patient. A team of reference in primary care (family doctor, nurse, health support services and social workers) will attend patients with chronic diseases by means of a new channel of communication which integrates new information and communication technologies. This way, his health status and his living quality will be improved while lowering health care costs (due to a reduction of presential visits and hospital admissions). Besides, an integral care will be

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to any healthcare entity related to supply chain management, tailor‐made manufacturing, industrial laundry, intelligent textiles, among others.

achieved, as both the clinical control and the social situation of the patient will be taken into account.

Samantha Robinson NHS Yorkshire and the Humber

Public authorit

y

NHS Yorkshire & the Humber (YH) was set up by the Government in July 2006 to act as the regional body for the NHS. 1 of 10 strategic health authorities for England, we are the headquarters of the NHS locally & act as a key link between the Department of Health & the NHS. The region has: •a population of 5.23million •covers 15,510 square kilometres including major cities such as Leeds & Sheffield & rural areas with scattered populations, especially in North Yorkshire. •over 148,000 staff working for the NHS •over £8.1billion invested in health care every year. Improving health in the region is at the heart of everything we do. Our ambition is to ensure that it is a healthy place to live with a health service that is a match for anywhere in Europe. Innovation is vital in driving sustained improvements in quality & productivity across the region & will help us deliver the national QIPP agenda, which focuses on delivering the best patient care in the most efficient way.

The Health and Social Care system in Yorkshire and the Humber (YH) as part of the English NHS has been at the forefront of introducing new participative service models for people with long term conditions utilising digital technology. We have extensive experience using Teleconsultation, Remote Monitoring and Telecoaching to bring proactive care closer to the individual, in their community. We have created assets, capacity and expertise to transform care by placing the citizen at the centre. With a deeper understanding and greater control of the factors that impact health and wellbeing, individuals flourish, remaining economically active and socially engaged. Our QIPP (Quality, Innovation, Prevention and Productivity) commitment builds on these foundations to further innovate in collaboration with citizens. It will ensure that best practice utilising technology becomes common practice. Our vision enables citizens to be fully active members of their communities, supported in their own homes and locally by a range of innovative technologies. This will enable them to manage their health status and improve their quality of life. Technologies being implemented include video conferencing to support clinical care, remote monitoring of physiological conditions, health coaching and web based applications and portals. Complementary activities to build and sustain community capital and to stimulate new business models and market entrants are actively being pursued.

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Teresa Moreno Spanish Collaborating Centre of the Joanna Briggs

Institute (Nursing and Healthcare

Research Unit)

Public authorit

y

The Spanish Collaborating Centre of the Joanna Briggs Institute is located within the Institute of Health Carlos III – as part of the Ministry of Economy and Competitiveness. It is established into the Nursing and Healthcare Research Unit (Investén‐isciii) which is the main Unit for Nursing Research at national level. The unit is involved in a national research network (RETICEF) in the field of frailty and elderly people, involving 28 research groups from basic to clinical researchers. The Centre is supported by 14 Spanish regions. The centre has international connections all over Europe and Latin America. Our principal aim is to help for the development, promotion and support of the evidence based approach to health care.

The project aims to establish Centers committed with the use of best practices (BPCC) to support Self‐Management in Chronic Conditions. The establishment of BPCC will allow us to implement and evaluate the developed best practice guidelines. It will be a dynamic partnership that focuses on making a positive impact on patient care though identifying strategies and interventions that enhance an individual’s ability to manage their chronic health condition. The main objective will be to determine/measure the effectiveness of an implementation of clinical practice guidelines through the creation of a national network of “Centers committed with the use of best practices to support Self‐management in Chronic conditions”.

Sytske de Vries Dutch Associated Health

Insurance Companies

Other

Dutch Associated Health Insurance Companies (Zorgverzekeraars Nederland) Zorgverzekeraars Nederland represents Dutch health care insurance companies. Nearly all Dutch healthcare insurers are a member of ZN. André Rouvoet is President of the Board of Governors of the association. The Board of Governors directs the bureau of the association. Pieter Hasekamp is CEO of the bureau and is assisted by Theo Hoppenbrouwers, Director of the Insurance Department and Tony Lamping, Director of the Care & Cure Department. The bureau of ZN employs appr. 100 FTE. ZN is responsible for the general tasks which ensue from the representative functions of ZN. These are focused on, for example, the preparation and implementation of policy, compiling

Dutch health insurance companies have the intention to work together on the implementation of ehealth. The aim is to work on a agenda to accelerate the implementation of ehealth in the Netherlands. The agenda will be finished by october/november 2012. It is under investigation ifand how care givers organisations and patinets groups will join the initiative.

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knowledge and skills, establishing and maintaining networks and providing service to individual members. In particular, communication with the members is an essential task. In part, these tasks are organised ac

Paul Laffin EUREGHA Public authorit

y

EUREGHA (European Regional and Local Health Authorities), a fee‐paying ASBL (non‐profit association according to the Belgian Law) was inaugurated in January 2012 and comprises 13 member regions from 8 EU member states. With no formal or political mandate it facilitates cooperation amongst subnational actors on health issues and reaches out across the EU to create synergies between the subnational level and other EU stakeholders on health issues. The network presents experiences from members through structured dialogue with the EU institutions and promotes activities aiming at increasing both understanding of regional health systems and recognition of the valuable contribution that sub‐national authorities can make to the development of EU health policy.

Ageing populations and financial constraints mean that the promotion of innovative integrated care programmes at the local and regional level is a EUREGHA priority and consequently we’ve been considering how the organisation, via its WG on IC – led by the EOEBO, could contribute to the delivery of the EIP’s goals and objectives. Specifically, we think that the collation of knowledge contained within our member regions can help to achieve the goals of Specific Action B3: Replicating and tutoring integrated care for chronic diseases, including remote monitoring at regional level by: • Mapping and collecting evidence on health and economic outcomes of integrated care models, in one repository • Identifying successful organisational models for integrated care, scalable and reproducible, and supporting their implementation in regions across the EU • Exploring the effectiveness of existing funding models and developing, where appropriate, alternative funding models • Coaching of regions: between "pioneering regions" with successful operational models and "follower regions" Essentially, we’d envisage hosting a conference on this topic which, along with the requisite preparatory activities and post‐event analysis, would allow our members and other interested regions – see below, to contribute to Specific Action B3’s goals through the exchange and dissemination of best practice in the aforementioned areas.

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Esther Davidsen Zealand Denmark

Public authorit

y

Region Zealand is one of five regions in Denmark, and is responsible for providing healthcare for 800.000 inhabitants. Region Zealand is responsible for hospitals, psychiatry, the system of primary physicians and highly specialized social institutions. Approximately 15.000 employees help secure the welfare benefits and development of Region Zealand. Most of the employees work in the health care system and in the psychiatric units. Region Zealand plays a central role in securing cooperation between partners, and work for a dynamic and coordinated development throughout the region, i.a. for business, education, urban development, public transport, health care and certain environmental areas. Region Zealand has a budget of around 2 billion Euros. The region is not financed by direct taxes but receives a budget from the state and the municipalities, for a set of given tasks.

Follow‐Up Home Visits is a project focused on avoiding unintended and unnecessary hospitalization of elderly patients with chronic diseases. These elderly patients often have multiple conditions and are in need of care both from the primary and secondary systems. When fragile patients are discharged from the hospital to their own home or nursing home, a lack of communication between the hospital, the primary system and the patient can result in unintended hospitalization after a short while. The problems are often a result of poor communication between the hospital and the care system, and this lack results in a poor quality in the patient care and costly unnecessary and unintended rehospitalizations. Unintended hospitalization is defined as acute admission between 4 hours and 30 days after the discharge. For some groups of patients over 67 years with specific diagnoses (stroke, dehydration, pneumonia, COPD, heart failure ect.) the readmission frequency in Region Zealand was 20 % in 2010. Studies show that this can be lowered significantly through a more systematic follow up scheme. In the Follow‐Up Home Visit Project, a specific group of elderly patients with chronic diseases receives up to three visits at home of both their primary physician and a nurse from the care system. The purpose is to assess progress, monitor medicine intake and need for care and rehabilitation. The first visit takes place 6‐8 days after discharge, the next 3 weeks and the last after 8 we

Bruno Trimarco FEDERICO II UNIVERSITY

Research/academ

ia

Federico II University Hospital is an excellence health care facility in Southern Italy, including over 50 Specialist Courses and master Degrees, providing in‐hospital admittance, day‐hospitals, day‐services and outpatient activities. Federico II Hospital takes part to the regional and national health care programs in

We propose to generate an integrated, web‐based network between the hospital, the outpatient clinic, general practitioners, territorial geriatrics, relatives and social assistant workers and volunteers to evaluate the impact of such organization on handling the high risk of the fragile elder patient. In our vision, the elder patient that is admitted in hospital is enrolled in a

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organ transplantation, maternal‐infant protection, AIDS, cardiology, heart surgery, the Regional Centers for kidney and bone marrow transplants, cardiovascular diseases and specific pediatric diseases, where high level of speciality care is provided. The hospital provides many opportunities to develop interdisciplinary activities, that are at the basis of innovation and translational medicine. Cardiology division provides competence in hypertension, heart failure, ischemia, arrhythmias, and a network of physicians connected via the internet for the follow‐up of chronic disease such as hypertension and heart failure.

follow up program at discharge, that encloses a short term visit in the outpatient clinic soon after. Within this first visit, prescriptions are made for the elder patients that are conveyed to the general practitioner attending the patient, and the territorial network is alerted, including the territorial geriatric, the relatives of the patient, and the social workers and volunteers of the territory. All care and cure providers are given controlled access to a web‐based database they can feed with new data regarding the patient after each visit. The purpose of such a network is the early identification of markers of evolution of the condition that if not corrected will lead to a new hospitalization. In this network, each stakeholder will be given controlled access to placing redflag alerts that will require the intervention from the hospital specialist, acting as the Case Master. The specialist will fill a new prescription, or require a new visit at the outpatient clinic of the hospital, or a new admission to the hospital, if required.

ANDRES CABRERA LEON

ANDALUSIAN SCHOOL OF

PUBLIC HEALTH

Research/academ

ia

The Andalusian School of Public Health (EASP, Spanish acronym) is a state‐owned enterprise created by the Andalusian Government, Spain, to support its Regional Health and Wellbeing Ministry through the development and coordination of professional training activities, consulting projects, research, and international cooperation efforts in the fields of public health and health services management. The EASP is a collaborating center with the WHO and the PAHO, and it is also a member of leading international public health and health management associations both in Europe and Latin America: EHMA, (European Health

The aim of OPIMEC is to enable clinicians, policy makers, managers, researchers, educators and members of the general public interested in complex chronic diseases, to generate new knowledge and share experiences across traditional boundaries, with a particular focus on older people. Easy‐to‐use innovative online social media resources support the platform that powers www.OPIMEC.org. This platform: • Allows anyone to create and upload documents • Includes information about more than 190 practices and links to more than 1400 resources of interest to clinicians, patients and caregivers • Links more than 1000 experts from more than 30 countries • Supports the co‐creation of knowledge by online communities, leading to groundbreaking products such as the book “When people live with multiple

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Management Association), ASPHER (Association of Schools of Public Health in the European Region), and ALAESP (Asociación Latinoamericana de Escuelas de Salud Pública). Its main clients in the autonomous Andalusian community are the Regional Health Ministry, the Regional Ministry for Equality and Social Welfare, and the Regional Andalusian Health Service (SAS).

chronic diseases: a collaborative approach to an emerging global challenge" • Convenes meetings (e.g., "Promoting High Quality Services for People living with Chronic Diseases") • Promotes recognition of innovations through the publication of regular newsletters • Contributes to capacity building efforts through virtual courses Improving Care for People with Chronic Diseases or Chronic Pain) • Facilitates the participation of its individual members and communities in international projects

Jose Luis Monteagudo Institute of Health Carlos III

Public authorit

y

The Institute of Health Carlos III is a Public Research Organization depending administratively of the Ministry of Economy and Competitiveness and functionally from the Ministry of Health, Social Services and Equality. ICT for Health is one of the strategic working lines of the Institute which is implemented through the Telemedicine and eHealth Unit which has a staff of 25 researchers. The main active research lines of the Unit are: Mobile Health; AAL (Ambient Assisted Living); information systems in healthcare; standardization and semantic interoperability in EHR; PHR and Archetypes; development of open platform (hardware and software) for the follow up of patients (chronically, elderly and dependent persons care); security and safety of the telemedicine applications and evaluation of new mobile telehealth services and its integration in the public Healthcare National System. It has a large experience of participation in European projects on ICT for Health under the 4, 5, 6 & 7FPs

PITeHS involves 9 innovation clusters in 8 Regions in Spain (Andalucia; Aragon; Cantabria; Castilla‐ La Mancha; Catalonia, Galicia; Madrid and Navarra) who have established practical telehealth and telecare initiatives addressing chronic long term conditions aiming to support healthier, longer lives for European citizens using new care models. Each of those nodes at PITeHS pilots practical applications respecting local and regional contexts and different healthcare services organizations. Those pilots are leaded by a relevant healthcare provider. In addition, they have associated clusters of local stakeholders such as authorities, SMEs, ICT companies, telecom operators, care professionals, health care systems managers, innovation promoters, researchers, and other interested parties. PITeHS relays on the development and wide diffusion of an open organisational, semantic and technical framework (PITeHS platform) aiming to foster the wide adoption of sustainable, efficient and reliable ICT based solutions for integrated chronic care. PITeHS development plans include increasing the number of participating nodes, thus widening the covered population, the involved stakeholders and the related ICT applications deployment.

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Francesca Avolio Regional Healthcare Agency of Puglia

Public authorit

y

Regional Healthcare Agency is the technical support of Healthcare Regional Government. It has a budget of 3 million €. Together with Health districts and Hospital Trusts is responsible of organizing healthcare services of the Region in order to guarantee the adequate delivery of services. Healthcare System is 60% of the total regional budget(about 7.5 M€ over a total amount of about 13.5 M€)and Ares is also responsible of guaranteeing the correct use of economic resources supporting top management in running the Healthcare service, planning the delivery of the service. The implementation of an integrated approach to chronic patients according to the Chronic Care Model, Systemic approach on Rare Diseases, Pharmacovigilance, Analysis, audit and assessment of health performances and innovation implementation; health Technology Assessment are part of its core activities. Ares represents Puglia Region in the “Interregional group on Health” in the Committee of the Regions in Bruxelles.

It is based on the promotion of the empowerment approach in an integrated system of care, by supporting, coaching, and educating patients ‐ by trained Nurses (Care manager) ‐ to self‐manage their condition, involving them in decision‐making related to their diseases. Patient education produces better adherence to follow up and compliance to treatment, improves patients and health professionals satisfaction, and improves clinical outcomes. The introduction of new professionals such as CMs helps the promotion of healthy lifestyles and also increases the changing of lifestyles by counselling patients.The project introduces the telemedicine as a basic tools to support CMs , GPs and specialists in treating patients improving care in quality, efficiency and effectiveness. Common training on quality systems, shared guidelines, clinical pathways, will be delivered to all involved health professionals to share objectives and methodology of the project. Data will be collected in a Web‐based database to support CMs in coaching and educating patients, to help the reporting about each patient to inform consulted specialists and for hospital admissions, to help action monitoring, and to facilitate statistical analysis. The model is expected to: Promote/increase health security through an integrated approach by care teams (GP, CM and Specialist); Reduce health inequalities facilitating proper access to healthcare service; Reduce need for access to Casualties & Emergency.

Máximo Bernabeu‐Wittel

Servicio Andaluz de

Health provider

Investigation in Polypathology and complex chronic diseases, advanced medical diseases, and clinical support to patients with surgical pathology from 2000‐2012. Leadership in the expansion of the benefits of a new model of assistance shared

The impact of the hip fracture (FxC) in the older is important, not only because of its high prevalence, the socio‐economic costs, but important morbidity and mortality that has associated this process. With the aim of enhancing functional independence and decrease mortality and hospital morbidity as well as the late

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Salud (Andalusian

Health Service)

between hospital care and primary care through the structuring of the area with population reference internists co‐adscribed to Primary Care health centres. Model for its advantages has already been exported to other health escenarios‐area of our autonomy and other autonomies as Madrid, C.Valenciana, Galicia, Castilla‐León and Castilla ‐ La Mancha, Spain. Definition and characterization in world medical literature of the emerging population of polypathological patients (PP). Landmark and paradigm of a new epidemiological, clinical and care population key to health‐care systems innovations. Authors of PROFUND index, PALIAR index, and IMPACTO project, leaders of PAHFRAC‐01 clnical trial.

(after 6 and 12 months of discharge) in patients with FxC., we have developed a hybrid perioperative comprehensive clinical support with multidimensional protocols medical interventions and subsequent Telerehabilitation program after discharge. The study is a cuasiexperimental trial. The study population are over the age of 65 with FxC osteoporotic who sign informed consent. Primary result are hospital mortality, mortality at 30 days of discharge and post‐alta mortality at 6 and 12 months. This study will provide evidence on outcomes in health and socio‐economic of a programme of comprehensive clinical support in FxC, by a multidisciplinary team and subsequent programme of TeleRehabilitation.

Christian Bourquin Région Languedoc Roussillon

Public authorit

y

The Languedoc‐Roussillon Region (budget of 1.2 billion €, 3200 members) has a mission for education, training, economic development, long‐term national and regional development, research and public health. Social care is key (highest population growth rate in Metropolitan France) and the Region has made important investments in training on health and primary prevention (health education programme for 15‐25 year olds). The Region supports many research programmes (5th best French centre of public/private research) particularly in biosciences. Health and social equity is a key issue and the Region finances a maison médicale pluridisciplinaire network in remote rural areas, an information programme on health for the

Chronic diseases (including cardiovascular diseases, chronic respiratory diseases, diabetes, osteoarticular diseases) cluster in multimorbidities. All stakeholders of the Région Languedoc Roussillon (LR) are engaged to move from pilot studies to full deployment of integrated care in the elderly. Under the leadership of the President of the LR‐Region, the University Montpellier 1, the university hospitals (CHU Montpellier and Nîmes) and the Agence Régionale de Santé propose to group existing and planned public and private (Orange, Horiba, Sanofi, LinkCare) activities of excellence in order to create an ambitious, innovative, stepwise, practical, feasible and measurable project centred around the patient (active involvement of patient organisations). Fighting CD will implement scalable, reproducible organisational and business models for integrated care. Multimorbidities will be assessed in the entire LR‐Region using

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elderly and an evaluation of interoperable independent living solutions. The Region is member of the GECT Pyrénées‐Méditerranée, co‐manager and delegated manager of European funds and was the first to launch JEREMIE (Joint European REsources for MIcro‐to‐medium Enterprises)

hospital‐based and mobile clinics. An integrated care programme using telemonitoring will be deployed, particularly in remote rural areas. Polypharmacy will be monitored by pharmacists using telemonitoring (Law L.1111‐23). Health and social carers will be involved. Teaching of end‐users is already in place. The objectives are to improve HLY and reduce unscheduled hospitalisations for chronic diseases in the Region by 30% in 2020 for elderly patients. Fighting CD is a priority for the LR‐Region policies which will be extended to other regions of Europe.

Kai Leichsenring European Centre for

Social Welfare Policy and Research

Research/academ

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The European Centre is a UN‐affiliated intergovernmental organization concerned with all aspects of social welfare policy and research. The core of research is on ‘Health and Long‐ term Care’ and on ‘Work, Wealth and Welfare’. The European Centre has coordinated and participated in a wide range of comparative international research projects, in particular in relation to the issues addressed by the EIP on active and healthy ageing, e.g. PROCARE (www.euro.centre.org/procare) and INTERLINKS (http://interlinks.euro.centre.org). On the website www.euro.centre.org all information about projects, events, websites and publications is enriched with downloads, cross‐references and external links.�

The FP7 Project "Health systems and long‐term care for older people in Europe. Modelling the INTERfaces and LINKS between prevention and rehabilitation, quality and informal care" (INTERLINKS) has resulted in the construction and validation of the INTERLINKS Framework for LTC with six themes, each of which has 2‐6 sub‐themes with 2 to 8 key‐issues. These key‐ issues have been illustrated by practice examples from individual countries that show the way ahead towards innovation and better coordination between health and social care, and between formal and informal care. This systematic Framework for LTC has been translated into an interactive website (http://interlinks.euro.centre.org), which is targeted at policy‐ makers, managers and organisations working in and with LTC to improve policies and practice by learning from innovative approaches. The involvement of National Expert Panels and a European Sounding Board since the beginning of this pro‐ject will ensure further use and dissemination of knowledge collected. This expertise fuelled an ample range of presentations and publications on national and European levels with the aim to further involve the wider public in the further development of the Framework and the website, e.g. by adding own ex‐amples

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and exchanging experiences in relation to their transferability and adaptation to the various developmental stages of LTC in European countries. Further activities are needed to roll out and scale up these experiences.

active and healthy ageing: b3 integrated...

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