Joining up ICT and service processes for
quality integrated care in Europe
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Background
• National welfare & health systems
and regional/local support practices
are developing more and more
specialisation and clear boundaries
closed them to cooperation
• Today’s reality is characterised by
fragmentation and bureaucracy in
current provision systems resulting in
disjointed and patchy support
services
• Leading to inefficiencies, duplication
of resources, and potentially to
reduced levels of quality of care
Healthcare Informal care Social care
Tomorrow
Today
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
SmartCare in a nutshell
• Started in March 2013 and will end in February 2016
• 42 partner organisations from health care, social care, research and policy across 15
European countries
• SmartCare services will be piloted in 9 European regions within the project duration;
further 13 regions participate to prepare for future service implementation
• Pursues a programme of systematic service process innovation complemented by
adaptation of technology.
• Multi-staged work programme enables the views of a wide range of stakeholders
being systematically taken into account: Older people with chronic conditions,
family carers, diverse health and social care occupations, service funding
organisations.
• Evidence-based planning and mainstreaming of SmartCare services by relevant
stakeholders will be enabled by a robust evaluation programme.
• Pilot A under ICT PSP Programme
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
The SmartCare Mission
• Improving co-ordination of care delivery across established
health and social services
• Developing and delivering integrated ICT-supported care services
for older persons who have complex needs to facilitate:
• Person-centred, co-ordinated care for individuals and their carers
• Greater levels of self-care and self-management
• A unified approach of the health and social care system
• Effective and efficient communication between all parties
• Better use of resources, less duplication and more streamlined care
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
The SmartCare Solution
• Harnessing ICTs for the benefit of older persons people and
those with chronic diseases
Integrated Long-Term Home Care Support
Personalised multi-provider service package
Entry point
(2):
Referral by
social care
provider Temporary
admission to
institution
(e.g.
hospital, care
home)
Monitoring /
review /
reassessment
of care
recipient’s
needs
Exit point:
Disenrollmen
t from
SmartCare
service (ICP-
LTCare)
Entry point
(1):
Referral by
health care
provider
Assessment
of care
recipient’s
needs for
long term
home care
Enrolment to
SmartCare
service (ICP-
LTCare)
Initial
integrated
care plan
Coordination
of integrated
care delivery
/ revision of
initial
integrated
care plan On-site /
home
provision of
formal social
care
Remote
provision of
health &
social care
(telehealth,
telecare)
Shared
documentatio
n of home
care provided
On-site /
home
provision of
formal health
care
On-site /
home
provision of
informal care
Entering into service Receiving continuous personalised care Leaving service
Integrated Home Support after Hospital Discharge
Entry point:
Discharge from
hospital
impending
Assessment of
care recipient’s
needs for home
care
Enrolment to
SmartCare
service (ICP-
Discharge)
Initial integrated
care plan
Discharge from
hospital
Coordination of
integrated care
delivery /
revision of initial
integrated care
plan
Shared
documentation
of home care
provided
Readmission to
hospital
Monitoring /
review /
reassessment of
care recipient’s
needs
Exit point:
Transition into
SmartCare long-
term care
service
Exit point:
Disenrollment
from SmartCare
discharge service
Entering into service Receiving continuous personalised care Leaving service
Personalised multi-provider service package
On-site /
home
provision of
formal social
care
Remote
provision of
health &
social care
(telehealth,
telecare)
On-site /
home
provision of
formal health
care
On-site /
home
provision of
informal care
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Key Care Pathway implementation Services/Activities
and associated ICT applications
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Information collection and recording
Systems
Personalised multi-provider service package
Entry point (2):
Referral
information
Social care
record -
paper/ER, GP
system
Temp admission
to institution info
Integrated H&SC
record –
paper/ER,
Hospital PAS, GP
system
Monitoring /
review /
reassessment info
Integrated H&SC
record –
paper/ER
Exit point:
Discharge info
Integrated H&SC
record –
paper/ER,
SmartCare
database, GP
system
Entry point (1):
Referral
information
Health record –
paper/ER, GP
system
Joint assessment
information
Integrated H&SC
record –
paper/ER
Enrolment and
consent
Integrated H&SC
record –
paper/ER,
SmartCare
database, GP
system
Initial integrated
care plan
Integrated H&SC
record –
paper/ER, GP
system
Care coordination
Integrated H&SC
record –
paper/ER
Integrated and
shared
documentation
Integrated H&SC
record –
paper/ER, CR self
care plan
Entering into service Receiving continuous personalised care Leaving service
Social Care onsite
services
Caseload
management &
appointment
systems, CR held
record
Remote provision
of health & social
care and support
Online platforms,
telehealth &
telecare
Health Care
onsite services
Caseload
management &
appointment
systems, CR held
record
Informal Carers
onsite services
Caseload
management &
appointment
systems, CR held
record
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Information, communication and
sharing mechanisms
Personalised multi-provider service package
Entry point (2):
Referral
information
Social care
record Temp admission
to institution info
Email, integrated
record, system
generated
message, fax,
phone
Monitoring/revie
w / reassessment
Email, integrated
record, system
generated
message, SMS,
fax, phone,
letter
Exit point:
Discharge info
Email, integrated
record, system
generated
message, fax,
letter
Entry point (1):
Referral
information
Health record
Joint assessment
information
H&SC record,
integrated
record, system
generated
message
Enrolment and
consent
H&SC record,
integrated
record, system
generated
message, paper
fax
Initial integrated
care plan
Community H&SC
record, email,
fax, phone
Care coordination
Community H&SC
record, email,
system generated
message, fax,
phone, letter
Integrated and
shared
documentation
Email, integrated
record, system
generated
message, fax
Entering into service Receiving continuous personalised care Leaving service
Social Care
Integrated record,
email, system
generated
message, fax,
phone, shared
paper diary
Remote provision of
health & social care
and support
Email,
telemonitoring
system, web-based
system, integrated
record, phone
Health Care
Integrated record,
email, system
generated
message, fax,
phone, shared
paper diary
Informal Carers
Integrated record,
email, system
generated
message, fax,
phone, shared
paper diary
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
ICT infrastructure
Personalised multi-provider service package
Referral
information
Community social
care LAN/WiFi,
broadband,
paper filing, GP
LAN
Temp admission
to institution info
Community
LAN/WiFi, GP
LAN, Hospital
LAN, paper filing
system
Monitoring /
review /
reassessment info
Community
LAN/WiFi,
broadband,
paper filing
system
Discharge info
Community H&SC
LAN/WiFi, GP
LAN, paper filing
system,
SmartCare
database
Referral
information
Community
health
LAN/WiFi,broadb
and, paper filing,
GP LAN
Joint assessment
information
Community H&SC
LANs/WiFi,
broadband,
paper filing
system, GP LAN
Enrolment and
consent
Community H&SC
LAN/WiFi,
Broadband,
paper filing
system, GP LAN
Initial integrated
care plan
Community H&SC
record –
paper/ER, GP
system
Care coordination
Community H&SC
LAN.WiFi, SPA,
Call Centre,
paper filing
system, GP LAN
Integrated and
shared
documentation
Community
LAN/WiFi,
broadband,
paper filing
system
Entering into service Receiving continuous personalised care Leaving service
Social Care
Community
LAN/WiFi,
broadband, paper
diary system, CR
home broadband,
paper record
Remote provision of
health & social care
and support
CR home
broadband, paper
record, SPA, Call
Centre LAN/WiFi
Health Care
Community
LAN/WiFi,
broadband, paper
diary system, CR
home broadband,
paper record
Informal Carers
Community
LAN/WiFi,
broadband, paper
diary system, CR
home broadband,
paper record
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Workplan
Requirements Elicitation & Care Pathway Development
Organisational & ICT-related pilot preparation
Pilot operation & evaluation
WP1 Requirements
& use case definition
WP2 Service process models
WP3 Integration architecture &
service specification
WP4 System
implementation & test
WP5 Pilot site preparation
WP6/7 Pilot operation
WP8 Pilot evaluation
WP9 Exploitation support & dissemination
WP10 Consortium management and performance monitoring
The 26 regions
participating in
SmartCare are members
of one of two different
groups:
• 9 regions will deploy
integrated health and social
eCare services
• 17 committed regions
participate to learn from
experience of the
deployment regions and go
through a programme of
service planning and
scenario-based piloting
SmartCare Regions
• Aragón is a region located at
the North-East of Spain with
a population of 1.3 million
• The region comprises three
provinces (Zaragoza, Huesca
and Teruel) and 731
municipalities
• 50% of the population lives in
the regional capital city,
Zaragoza, while the
remaining 50% is sparsely
spread among the rest of the
municipalities
Aragón, Spain The region
Healthcare system
• 1 only health provider (SALUD)
• Public body
• Primary Care + Specialized services + Mental health
• One only ICT Infrastructure. Same network, common DBs,
management APPs + Intranet giving access to all information to
all health professionals in all the territory,
Social care system
• Several providers (public & private)
• External funds (Public grants or membership + public grants)
• Each provider offers its own basket of services
• Users ask for services to any provider. Those can be granted if
the user fulfils requirements. There might be duplicities of
services
• Each provider has its own Information Systems
– Databases are independent
– No citizen’s data shared among them
Aragón, Spain Social and Healthcare Service provision
…
• SALUD – Common ICT infrastructure for Primary Care &
Specialized Care
– Same network, common DBs
– SALUD IS: – EHR Viewer (Primary Care + Specialized Care
patient data)
– HIS: Scheduling & monitoring information apps
– Departmental apps (PCH, LIS, RIS, telemonitoring portal, Patient’s surveys, e-prescription)
– Videoconferencing system
– unique EHR for Primary Care + Specialized Care
– Help desk
• SOCIAL care providers – Social Services Recording IS
– Proximity Local App: Contact centre + agenda
– Citizens info databases
• Informal carers – Proprietary systems/None/paper
SALUD
PCH
(Urgencias) RIS
LIS
(Laboratorio)
HIS
(Admisión)
BDU
PACS
GESTOR
DE
PACIENTES
SALUD
INFORMA
EMPI OMI-
AP
Departamentales
Farmacia Informes
(HP-Doctor)
Cartera de
Servicios
AGENDA
PRIMARIA
AGENDA
ESPECIALIZADA
…
INTRANET
Motor
Integración
(Rhapsody)
Social providers
Aragón, Spain Existing IT infrastructure
Common
Framework
CARE
RECIPIENT
INFORMAL
CARER
HEALTH
PROVIDER
SOCIAL
PROVIDER
Aragón, Spain SmartCare infrastructure
• Collaboration platform for the provision of Integrated Care - SmartCare platform – Accessible by all care agents involved on the provision of
care
– All agents share data (minimum data set) • SALUD shares IT and clinical data
• Social providers share social data
– Integration with the already existing information systems
• Unique point of data on integrated care provided to citizens – Sharing of clinical and social data
– Common basket of integrated-care services
• Collaboration platform to ease the collaboration among organizations & encourages participation of professionals – Collaboration framework to define commonly the integrated
care plan
– Schedule the activities for the provision of the services
– Documentation point
• SALUD & IASS under the same Aragon Government Department. Alignment of policies and strategies
– Single unique identifier of users in the social and healthcare Aragon Systems. (BDU)
• Initial deployment so as to lead and define the change management in SALUD
Attikí, Greece The region
• Attica encompasses eight
dirstricts
• Social care services are delivered
through 193 community centres
and five day care centres
• Home help programme
• Healthcare services are provided
by a network of 199
public/private hospitals and
primary care centres
SmartCare in Attica
• Implementation in Alimos, Agios
Dimitrios and Palaio Faliro
• Joining-up service delivery to older
people living with Type II diabetes
and their caregivers
• Service users will receive
personalised information and
guidance on how to self-manage
their condition through an Electronic
Platform
• Community nurses, dieticians, social
carers and diabetologists provide
coordinated care
1
Care Recipients
Patient Record
Patient Record
ATTICA Pilot Porta;
Hospital nurse
Diabetologist
Community Nurse, Care Coordinator
CR
Record
Dietician
Patient record
Social Worker
client
record
CR, FC Record
Updates patient data
Updates patient data
Updates patient data Updates client data
Updates patient data
Family carer
Updates data ( e.g. self measurement), uses messaging & video consultations
Automatic monitoring data
Data reports, messaging, video consultations
Attiki: Concept & Approach
Etelä-Kariala, Finland The region
• In Finland self-governed
municipalities have the main
responsibilities for providing basic
social and healthcare services
• South Karelia pursues a dedicated
policy ensuring equal access to
joined-up social and healthcare
services
• South Karelia Social and Health Care
District (Eksote) organises provision
of primary and secondary
healthcare, elderly care and social
care under a single roof
SmartCare in Etelä-Kariala
• Enables better co-operation between social and healthcare
professionals operating under the same organization (Eksote)
• Aim is the keep elderly people at home by providing them the
wider range of services to home
• Support elderly daily living by developing more integrated
home care supported by telecare
• Social care support using telecare
– Video phone connection
– GPS tracker
• Shared Care plan accessible online by service user, family
carer and social care/healthcare professionals
Etelä-Kariala: Concept & approach
• Italian border
region located in
the heart of
Europe
• The capital is
Trieste. It has an
area of 7,856
km² and about
1.2 million
inhabitants
Friuli Venezia Giulia, Italy The region
Mar
ino
Ste
rle
©Marino Sterle
• Friuli Venezia Giulia Region has defined a model of
integrated system of social and health care services: – The promotion of home care and community-based care through
the partnership between Municipalities and Local Health
Authorities and the involvement of the Third Sector
– Innovative models for integrated care: multi-dimensional and
cross-sectorial evaluation of needs, person-centered project,
integrated care provision, continuity of care
– Innovative tools for local integrated health and social planning:
Territorial Activities Program (PAT) and Local Plan for Social Policy
(PdZ, Piano di Zona)
– Joint initiatives with research/innovation (ICT) and housing
sectors
Friuli Venezia Giulia Background
• Integrated care models implementing the two pathways
• 200 patients to be recruited, locally randomized study
design (100 in usual care control group, 100 in “new ICT
supported integrated care” intervention group).
• Health care, social care, third sector, informal care
enrolled
• Target population
- Age >50
- At least one moderate-to-severe chronic condition (HF,
diabetes mellitus, COPD).
- End users with social needs (social isolation, insufficient or
inadequate social, or family support, need for environmental
monitoring). Identification of social frailty to be made as per one
BADL missing item.
SmartCare in Friuli Venezia Giulia
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Usual care
Intervention Group
Usual monitoring system
Permanent monitorin system
Outcomes
Initial evaluation data
Mid term evaluation data
Final evaluation data
Compared
analysis
Friuli Venezia Giulia Monitoring system - Smart Care Service vs. Usual Care
Enrollment
• Located 180 km south of
capital Belgrade
• Inhabitants 125.500
• Average age is 42.3 years
• Over 31.500 are 60+
• From which 1.800 had some
form of social protection
• Healht Centre Kraljevo (PHC)
has a separate organisational
unit for Home care
• Center for Social Work is basic
unit that provides social
protection
Kraljevo, Serbia The region
Challenge
• Currently no electronic
communication between
social and health
providers in Kraljevo
• Information exchanged
with paper documents
using post service
• Poor IT infrastructure
Our Goal
• To connect two
institutions using new ICT
technologies
• To create new services
from both social and
health domain
• Benefit for the end users
and care professionals
Kraljevo, Serbia Background
SmartCare service in Kraljevo
• Netherlands:
– Decentralized unitary state
– Bismarck care model
• Noord-Brabant:
Noord-Brabant, Netherlands The region
©Verse Beeldwaren
• Decentralised service delivery system.
– National government is responsible for health
care and general insurance matters.
– Social services are provided by non-profit
organisations, which are funded by the state,
local authorities and social insurance.
– Recent health care sector reforms to introduce
more competition and to shift decision power
to regional and local governance levels.
Noord-Brabant, Netherlands Background
• Regional strategy.
– Facilitating the integration of hitherto separated care chains by the
development of an electronic platform enabling a reliable electronic
exchange of care related data across a variety of stakeholders.
• Cardiac rehabilitation:
– Multidisciplinary intervention for physical and psychosocial recovery
after a cardiac event or intervention with proven beneficial effects
on morbidity and mortality.
– All stakeholders will work together and exchange data:
• Cardiac patient
• Informal carers
• Health care professionals
• Social workers
• Need for:
– Increased cardiac rehabilitation program uptake
– More sustained effects on cardiovascular risk behaviour
SmartCare in Noord-Brabant
• Focus on cardiac telerehabilitation using a personalized
patient-centred ICT platform enabling self-management
and collaborative monitoring and coaching.
– Home-based exercise program comprising remote monitoring and
coaching of physical activity behaviour, by using wearable sensors.
– Various treatment modules such as education, dietary interventions,
weight reduction and smoking cessation.
– Improved impact on self-management skills and self-efficacy to
induce more sustainable lifestyle changes.
– Tool to enable collaboration, highly-secured exchange of medical
information, and sharing of treatment goals.
Noord-Brabant, Netherlands
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Scotland, United Kingdom Background
• NHS 24 has a national
responsibility in Scotland as
advisor, facilitator and
promoter of technology
enabled health, care &
wellbeing for 5.2m population
• SmartCare’s overarching pop –
1.1m (20% of Scotland’s
population)
• Project involves :
– seven local authorities and three
territorial Health Boards
– Range of voluntary, charitable &
independent sector organisations
– Service users and carers
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
SmartCare in Scotland aims…
• To improve the health, care and wellbeing of 10,000
people aged 50+ within Ayrshire and the Clyde Valley.
• It will do this through better co-ordination and an
improved approach to falls prevention and
management.
• It will fully utilise ICT services and applications that are
vital in supporting integrated care
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
SmartCare in Scotland is…
• SmartCare is a new online person centred service which aims to
support people who are at risk of a fall or recovering from a fall.
• The service promotes enablement, self care, information sharing
and care coordination.
• The service will benefit people managing a long term condition
who want to remain independent in their own home
• It will also support their family, carers, Health and Social care
sector and providers supporting them.
• Integration on
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Scotland User stratification
Intense
support
Rehabilitation and enablement
Staying independent
Community wellbeing
38
Hospital or care home
Incre
asin
g F
railty
Diary and PHF
Diary and PHF
Self Assessment
Tool
LiU – Self Care Hub
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
ICT-enablers in Scotland
The region
• 1 of 5 administrative Regional Authorities in Denmark
• Inhabitants: 1.2 Million
• Main responsibility:
– Health provision
– Regional development
• 22 Municipalities (social care)
• 800 GP’s
• 4 hospital units – 1 university hospital
• Driving force behind the establishment of MAST
The structure - Health and social care needs to collaborate to take into account continuous care
The mentality -New cross-sectorial mindset was needed to focus on the care pathway and a citizen-centered approach
We needed IT to support the patient-centered focus across sectors
Challenge
Homecare
systems
- EPR
Electronical
patient record -
EPR
Medical system
Data
collection
Platform
The patient’s
individual plan
Information about own
conditiom
Entering data and
measurements
Questionnaire
Social care Hospital Medical practice
We needed...
Hospital Municipality GP
EHR ESR EHR
Shared Care Platform
Smar
tCar
e
SmartCare service in RSD
Existing Infrastructure + Electronic Messages (MedCom) +
Collaboration guidelines (SAM:BO) + Shared Care Platform
=
SmartCare service in RSD
Tallinn, Estonia Background
• The region of Tallinn
encompasses 8 districts
• Healthcare services tend to be
delivered mainly by publicly
owned hospitals under private
regulation and private primary
care units.
• Responsibility for social care
rests with more than 200
municipalities throughout the
country.
• Implementation of a nation-wide
electronic health information
system
SmartCare services in Tallinn
• Provides better joining-up of service
delivery across all districts.
• Care coordinators at the municipal
level are enabled to access the
SmartCare integration
infrastructure through a dedicated
portal with the help of the national
ID card used to access the national
health information system.
• Health care professionals and family
carers – on consent – will be granted
access as well.
• A dedicated contact centre serves
as a coordination hub vis-á-vis
further service providers, including
telemonitoring services and a social
alarm service.
Tallinn Service Specification
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Evaluation PICO-criteria
• Population
– Users of health & social care services
• Intervention
– SmartCare services
• Comparator
– Usual care
• Outcomes
– Quality, timeliness, effectiveness, cost minimizing
• Evaluated through the MAST framework
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
MAST adapted to SmartCare
MAST domain Health care Social care Volunteers/relatives
1. Health problem and characteristics of application
1. Health problem and characteristics of application
1. Social problem and characteristics of application
1. Health and social problem and characteristics of application
2. Safety 2. Safety 2. Safety 2. Safety
3. Clinical effectiveness
3. Clinical effectiveness
3. Care effectiveness 3. Clinical and care effectiveness
4. Patient perspectives
4. Patient perspectives
4. End-user perspectives
4. End-user perspectives
5. Economic aspects 5. Economic aspects 5. Economic aspects 5. Economic aspects
6. Organisational aspects
6. Organisational aspects
6. Organisational aspects
6. Organisational aspects
7. Socio-cultural, ethical and legal aspects
7. Socio-cultural, ethical and legal aspects
7. Socio-cultural, ethical and legal aspects
7. Socio-cultural, ethical and legal aspects
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Study design
• Deployment sites
– Intervention
– Control
• SmartCare
– Meta-analysis
– Meta-regression
– If possible, individual patient data meta-analysis
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Outcomes, database
MAST domain Health care Social care Volunteers/relatives
2. Safety Deaths, Technical safety
3. Clinical effectiveness
Health and social care services’ effectiveness
Number of contacts: Physical, mail, telephone
4. Patient perspectives
End-user perspectives Empowerment
5. Economic aspects WP 9
6. Organisational aspects
SmartCare questionnaire + process evaluation
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Supporting service mainstreaming
Policy level
Service level
Individual / organisational level
•Upscaled, societal SER
•„Should this become the way of doing things?“
•Service SER, ROI and time to break even
•„Under what conditions is the service viable?“
•Service-related costs and benefits
•„Under what conditions do we want to get involved?“
SER = Socio-economic return, ROI = Return on investment
A dedicated strand of activitiy deals with business case modelling, underpinned by cost-benefit analysis. Outcomes will provide deployment region with the necessary evidence-base to mainstream the delivery of integrated care services.
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Cost-benefit analysis
Cost-benefit analysis is used to economically evaluate the services and prospectively model different scenarios for service upscaling.
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
User Advisory Board
• AGE Platform Europe
• European Patients’ Forum
• European Federation of Nurses
• Eurocarers
• AOK (insurers)
• International Federation for Integrated Care
(IFIC)
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Objectives of the UAB
• UAB: a group aiming to gather information and
reflect on all users-related aspects
• Integrated care with users and not only for
users
• Capacity to support exchange and sharing of
practices among deployment sites from a user
perspective
• EU-wide organisations: multiplier effect
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Investigation of:
• Structures, means and resources available for
the ICT solutions for integrated care
• Involvement of informal carers
• Management of the SmartCare process
• Quality of service
One main UAB activity: Visits to
SmartCare deployment sites
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Committed Regions Board
• Regions being SmartCare partner already (13)
• New regions joining the CRB (7+)
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Objectives
Prepare regions for future deployment of
integrated eCare service:
• Use experience from deployment sites to boost
preparation
• Follow process design & implementation
• Stimulating political leadership in the regions
• Raise awareness and inform regions for the
uptake of integrated care service across Europe
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Consortium
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Information & Contact
For more information please visit
www. pilotsmartcare.eu/
and follow us on Twitter @PilotSmartCare
Or contact us at
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
ADDITIONAL SLIDES
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Formal side of SmartCare
• Funding programme: Competitiveness and Innovation Programme (CIP), ICT Policy Support (ICTPSP) sub-programme
• Funding instrument: Pilot type A (main beneficiaries are governmental bodies)
• Starting date: 1st March 2013
• Total investment: 16,000,000€
EU Contribution: 8,000,000€
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Integrated Care – supporting key
functions through ICT
• Care co-ordination
• Information sharing
• Joint, integrated assessment and care planning
• Support for self care and self management
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
SmartCare deployment sites
The project is partially funded under the ICT Policy Support
Programme (ICT PSP), grant agreement number 325158
Dissemination strategy
Publications in / special issue of the
Early adopter regions Local/regional/national-level service providers & funders
User organisations (older people, informal/voluntary carers)
Relevant research / policy actors
Relevant technology providers/ integrators
Project leaflet, brochure, newsletter
Approach, objectives Requirements
Partner regions
Useful integrated care
pathways
Useful integrated care pathways Fit-for purpose service
specifications/design
Preliminary expectations on benefits &
economic validity
Evidence on user acceptance Technical infrastructure & integrated service model
SmartCare guidelines and specifications
Benefits & economic viability, business models
Project Phase I: Integrated care pathways
development
Project Phase II: Organisational & ICT related pilot preparation
Project Phase III: Experiencesfrom pilots & transferability
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Dispersed audience: Interested expert
circles
Public at large
EIP AHA Action Groups (B3)
Project website SmartCare: http://www.SmartCare.eu (tentative)
Social media sites
representations
Prevention, screening
& early diagnosis
Care & Cure Active ageing &
independent living
•Health literacy, patient
empowerment, ethics and
adherence
•Personal health
management
•Prevention, early
diagnosis of functional
and cognitive decline
•Guidelines for care,
workforce
(multimorbidity,
polypharmacy, frailty
and collaborative care)
•Multimorbidity and R&D
•Capacity building and
replicability of successful
integrated care systems
•Assisted daily living for
older people with
cognitive impairment
•Flexible and
interoperable ICT
solutions for active and
independent living
•Innovation improving
social inclusion of older
people
Vision / Foundation
•Focus on holistic and multidisciplinary approach
•Development of dynamic and sustainable care
systems of tomorrow
•New paradigm of ageing
•Innovation in service of the elderly people
•Regulatory and standardisation conditions
•Effective funding
•Evidence base, reference examples, repository for age-friendly
innovation
•Marketplace to facilitate cooperation among various stakeholders
Horizontal issues
Presentations Workshops
Special events,
supported by:
Presence in the media in participating regions
Final
SmartCare
Confe-
rence
Links to other
projects, initiatives
Marketplace
IFIC
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