Description du projet
Preparing large scale deployment of targeted services to support active and healthy ageing ¿ Wide deployment of integrated care
CareWell will enable the delivery of integrated healthcare to frail elderly patients in a pilot setting through comprehensive multidisciplinary integrated care programmes where the role of ICTs can foster the coordination and patient centered delivery care. Carewell will focus in particular complex, multi-morbid elderly patients, who the patients most in need of health and social care resources (35% the total cost of Health Care System) and more complex interventions due to their frailty and comorbidities (health and social care coordination, monitoring, self-management of the patient and informal care giver). ICT platforms and communication channels that allow sharing information between healthcare and social care professionals involved in the delivery care of these patients, facilitating their coordination, increasing their resoluteness and avoiding duplicities when tackling patients´ diagnostic, therapeutic, rehabilitation or monitoring needs. Additionally, ICT-based platforms can improve the adherence to treatment, enhance self-care and increase patient awareness about their health status , as well as, improve the empowerment of informal caregivers, who usually take care of these patients. According to this, the benefit of integrated care programmes based on (1) integrated care coordination and (2) patient empowerment & home support pathways supported by ICT is greater and essential for these patients. Care pathways will cut across organisational boundaries and will activate the most appropriate resources across the entire spectrum of healthcare and social care services available for both scheduled and emergency care. CareWell aims to scale up the services in pioner regions and share their approach, learning from and supporting the other pilot sites which are at different levels of maturity in respect to designing, developing and implementing new ways of providing integrated care services.
CareWell will enable the delivery of integrated healthcare to frail elderly patients in a pilot setting through comprehensive multidisciplinary and tightly knit programmes. ICTs will play a major role in the coordination and communication of healthcare professionals and of patient centred delivery of care at home. CareWell will predominantly focus on the provision of care and support to older people who have complex health and social care needs, are at high risk of hospital or care home admission and require a range of high-level interventions due to their frailty and multiple chronic diseases. This will be achieved through ICT enabled health and social care services coordination, monitoring, patients self-management and informal care givers involvement. The ICT platforms and communication channels will avoid duplication of effort when dealing with patients´ diagnostic, therapeutic, rehabilitation or monitoring and support needs. Additionally, ICT-based platforms can improve treatment compliance, enhance self-care and self-management and increase patient and carer awareness on their health status. All of which will improve clinical outcomes and enable people to lead fulfilled lives. Moreover technologies will support the patients' informal caregivers highlighting when respite care or additional professional input is required. The two CareWell services are based on (1) integrated care coordination and (2) patient empowerment & home support pathways supported by ICT. These care pathways will cut across organisational boundaries. They will activate the most appropriate resources healthcare and social care services available, both for scheduled and unscheduled care. Information sharing will need to comply with European and national regulations relating to consent and privacy. The ICT platform will be based, whenever possible, on open standards and multi-vendor interoperability and collaboration among ICT suppliers will be strongly encouraged.
Appel à propositions
CIP-ICT-PSP-2013-7
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Régime de financement
PB - Pilot Type BCoordinateur
48902 Barakaldo
Espagne