Germany - Gesundes Kinzigtal

Scotland

Northern Netherlands - Groningen

Region of Southern Denmark

Basque Country

Catalonia

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Germany - Gesundes Kinzigtal


Programme:

  • Health coaching ”My Health”

Target Group:

  • Risk patients in need of care intervention, e.g. chronic diseases, multimorbidity

 

The overall aim of “My Health” lies in the ability to adapt the existing programmes to the specific needs and wishes of people living in Kinzigtal region, as well as getting much closer to the subject of multi-morbidity. Regarding the new developments, Gesundes Kinzigtal is about giving the patient the opportunity to individually select elements of programmes, trainings, education, and self-management courses. These kinds of modules cover very clear topics, such as medicine, therapy, medication, exercise, and relaxation. Every module has a great number of health offers that could be either a training module, a self-management module, a psychotherapeutic brief intervention, or a particular module where the practice assistant is regularly involved. All the physician has to do, is to prescribe the consultation with his recommended modules and make an appointment for his patients. The coaching consultation itself takes place at different locations in the cities and villages of Kinzigtal with respect to multi-morbid people with limited mobility.

The new care approach “My Health” including the new professional role as a health consultant lowers the barriers for patients to enter in health activities and improves cost effectiveness of the integrated care model in the long term. Tasks of this health consultant will mainly incorporate the arrangement of the new care modules and health care services based on physicians’ recommendations and the individual preferences of the patient. The physicians can be relieved from their bureaucratic workload for enrolment and giving detailed information about care services, while still being up to date of the care treatment process by looking in to their electronic patient record, where the consultant enters the results that were agreed with the patient directly after the consultation appointment. Consultants will be qualified and trained to be prepared for this kind of task. However, there is no need for extensive medical knowledge because ultimately the direction is already determined by the physician and by the modules and contraindications. Therefore, this approach can be easily transferred to other regions in Germany.


 

Programme:

  • World of Training

Target Group:

  • Risk patients e.g. with obesity, osteoporosis and need of muscular skeletal strengthening

 

Since the beginning of 2016 Gesundes Kinzigtal established a training centre in their facilities. On the one hand, the training centre, so called “world of training”, contains a training area for physical training equipped with modern electronic training devices that are also approved for rehabilitation. On the other hand, it offers the world of training group activities lead by a qualified coach for people after a certain period of rehabilitation suffering from diabetes or muscular-skeletal diseases.

The electronic documentation of the training results allows the coaches to control and eventually adapt the training plan. Furthermore, the physician that is responsible for the medical treatment is able to access this data. The training considers primary and secondary prevention, but focuses on personalised physical training for the target group of elderly frail people. Therefore, the training is scheduled to ensure that a staff member is nearby in case training support is needed. The training is accessible for everybody but provides different membership fees based on whether the person is a member of Gesundes Kinzigtal, assured in the AOK or not.

Scotland

Programme:

  • Diabetes self-management – online records access

Target Group:

  • Diabetes patients

 

            My diabetes my way1

MDMW is an effective low-cost population-based self-management intervention. Evaluation has shown high-levels of user satisfaction, and more recent analyses have shown statistically significant improvements in routinely collected process outcomes amongst active users. When extrapolated across a large population, MDMW may offer significant cost savings through the reduction of long-term complications and associated treatments.

The aim is to rapidly scale the active and routine use of the MDMW service amongst the ~283,000 individuals with diabetes in Scotland who do not currently access their records. Activities will include improved signposting from Primary Care (where most people with type 2 diabetes in Scotland are treated), targeted mailouts and presentations at local events. Strategically, MDMW supports the Scottish Government’s 2020 Vision for Health and Social Care, which aims to provide the “person-centred tools required for people with diabetes to live longer, healthier lives at home through supported self-management”.

Programme:

  • Diabetes telemonitoring services – foot screening

Target Group:

  • Diabetes patients / private podiatrists

 

         My diabetes my way

In 2015, NHS Scotland achieved its strategic goal of 80% of all people with diabetes having received foot screening within the previous 15 month period. Since changes to the Primary Care contract in 2016, screening levels have dropped to under 70%, meaning that patients who are not being screened are at higher risk of developing active foot disease. At present, 20% of patients receive podiatry screening outwith NHS services and their data are not transferred back to the service.

The aim is to develop functionality within MDMW to allow the collection of foot screening data using the NHS Scotland standard diabetic foot screening method: FRAME (http://www.diabetesframe.org/). This will allow patients to log-in to their electronic records while attending their private podiatrist, allowing the required data collection by a qualified practitioner, before onwards transmission to NHS systems. This proposal has gained the support of private podiatrists and the Scottish Diabetes Foot Action Group, who will actively promote the service once it goes live.

Northern Netherlands - Groningen


 

Programme:

  • Asthma / COPD telemedicine

Target Group:

  • Asthma and COPD patients

In the Netherlands, 60% to 80% of asthma and COPD patients are treated by their GP, and only referred to pulmonologists in cases of uncontrolled asthma or severe COPD. However, distinguishing asthma from COPD and other pulmonary problems is difficult. Early treatment can enhance asthma control, reduce morbidity, and improve the quality of life. This telehealth management support service assists GPs by examining patients and providing detailed advice from pulmonologists.

The aim is to provide an accurate and easily accessible service for GPs and patients, including also rural areas. Every patient suspected of having asthma, COPD, ACOS or who presents with pulmonary symptoms of unknown origin is eligible for inclusion.


 

Programme:

  • Embrace – Connecting health and community services

Target Group:

  • Citizens above the age of 75
embrace

More than 50% of people aged 60-plus suffer from multiple chronic conditions, and this percentage will increase in years to come. Despite the array of health services they use, older adults do not always receive appropriate care. This often leads to difficulties participating in treatment, and even treatment errors.

Embrace connects the health system with community services, and reflects the four key elements of the Chronic Care Model (CCM): self-management support, delivery system design, decision support, and clinical information systems. These are combined with a population health management model in terms of the Kaiser Permanente triangle to classify community-living older adults into risk profiles. Suitable levels of care and support are applied to each risk profile.


 

Programme:

  • Heart Failure Programme

Target Group:

  • Complex heart failure patients
effective-cardio

Congestive heart failure (CHF) is a complex and increasingly common clinical syndrome. The guidelines of the European Society of Cardiology recommend a multidisciplinary approach, often implemented as personal follow-up visits. Telehealth uses IT to assist in the management of a long-term medical condition of a patient at home. This lessens the burden on cardiologists. The telemonitoring system checks patient vital signs (blood pressure, pulse, weight) daily. Patients also receive videos on topics such as symptoms, daily care, compliance, and relapse prevention. The aim is to demonstrate how telemonitoring can be integrated in the care pathway, to measure the impact on workload, patient and staff satisfaction, and the economic consequences for hospitals.

Region of Southern Denmark


 

Programme:

  • Video Consultation for relatives

Target Group:

  • Citizens with hematologic diseases and their relatives
      VC for Relatives

Video Consultations have been implemented in several areas in the Region of Southern Denmark and this type of service is crucial to health care delivery and communication in the region for citizens, relatives and care professionals. Therefore, scaling is a political requirement as video consultations have been proven to be a good solution for the care professionals and citizens in many different clinical areas.

In ACT@Scale, RSD will focus on upscaling video consultations in the region but with a specific focus on the case of haematology patients at Odense University Hospital (OUH) to ensure that the relatives of this type of patient can attend consultations even if they are not able to attend in person.

The department of haematology at OUH provides highly specialised functions within the following areas for citizens in Region of Southern Denmark, i.e. up to 1.2 million citizens:

Acute leukaemia, Aplastic anaemia, Amyloidosis, Malignant lymphoma subtypes including Hodgkin’s Disease, Stem-cell supported high-dose chemotherapy, Rare benign haematological diseases, e.g. thrombotic thrombocytopenic purpura, Follow-up after allogeneic stem cell transplantation, Mastocytosis, and Eosinophilia.

The department has two projects in the field of telemedicine, i.e. the delivery of consultations and expertise at a distance.

  • Telecommunication between the patients and doctors at the hospital in Odense. For now it is patients living at Ærø (a small island south of Svendborg), but the plan is that it will be a routine service to all patients in RSD.
  • Video consultations as part of the ward rounds, where relatives can be part of the ward rounds “at a distance” through video consultations.

Basque Country


 

Programme:

  • PIP Multimorbid

Target Group:

  • Complex multimorbid patients
multimorbid-integration

This multimorbid programme has been developed by a multidisciplinary team formed by primary healthcare professionals, specialists, and managers with expertise in the development of the design of new pathways to care for older people with complex health and social care needs. These people are at high risk of hospital or care home admission. This is achieved through ICT-enabled health and social care services coordination, monitoring, carer involvement, and patient self-management. ICT-based platforms can improve treatment compliance, enhance self-management, and increase patient and carer understanding. The programme helps to improve clinical outcomes and enable people to lead fulfilled lives. The technology will highlight when respite care or additional professional input is required.


 

Programme:

  • Telemonitoring services for CHF

Target Group:

  • HF patients
chf-telemonitoring

Due to population ageing, chronic heart failure (CHF) is becoming more common. It will become increasingly difficult to maintain the quality of care. Home telemonitoring is a promising solution, allowing healthcare professionals to follow up a patient´s health status more closely and facilitate early symptom detection. Patients transmit their parameters at least once per week. The telemonitoring devices send the data to the gateway in the patient’s home. This transmits the data to the Telecare Centre, where the operator checks the data. When clinical parameters are out of range, the operator verifies the alarm situation by a phone call to the patient. The Telecare Centre resolves any technical problems arising in the use of devices.

Catalonia


 

Programme:

  • Healthcare support programmes for nursing homes

Target Group:

  • Elderly living in institutionalised homes
nursing-homes

A healthcare support programme for nursing homes launched in 2009 in Barcelona has been developed by teams of care homes (EAR). It comprises medical professionals and those with healthcare expertise in serving older people in nursing homes, understanding that these are indeed their homes.

Its aim is to provide comprehensive care, focusing on the individual. It seeks to adapt health and social resources and improve pharmaceutical services.

EAR teams work with the nursing homes’ healthcare professionals, with primary healthcare professionals, and other healthcare resources, to ensure healthcare continuity to this population.


 

Programme:

  • The Chronic Patient Programme – Badalona Serveis Assistencials

Target Group:

  • Complex chronic and frail patients
chronic-care

Badalona Serveis Assistencials (BSA) is an integrated private care organisation, entirely funded by public capital. It manages the Hospital Municipal de Badalona, the Homecare Integrated Service, the Socio Health Centre El Carme, seven Primary Care Centres and the Centre for Sexual and Reproductive Health, providing care to a population of 419,797 inhabitants. Social services provision started in 2000, with full integration of health and social services since 2003.

Its objective is to focus on identifying, preventing and treating in advance acute episodes to avoid further hospitalisations; design and implement individual integrated care plans based on the evaluation of particular need and the general geriatric evaluation; promote independent living for these patients while maintaining good quality of life; and coordinate the work of the interdisciplinary teams doing the interventions.


 

Programme:

  • Support of complex case management – AISBE

Target Group:

  • Complex patients that require linking tertiary care with the community
complex-case-management

Complex case management aims for large scale deployment (ca. 3,000 patients) by integrating successful clinical programmes linking tertiary care with the community (Type I diabetes mellitus, rare diseases, LTOT, non‐invasive home-based ventilation, cardiac failure, HIV‐AIDS, COPD, major ambulatory surgery, sleep disorders, home hospitalisation, support pre‐and post‐surgical high risk procedures, etc.).

A specific programme addressing the management of multi‐morbid patients is included. Patients fulfil one of the following three criteria of complexity:

  • Need for highly specialised services directly delivered into the community
  • Need for coordination of several professionals across healthcare tiers
  • Need for management of frailty due to functional impairment and / or risk of social exclusion.

The aim is to coordinate care management of complex cases. Adaptive case management will be a core component. Tele-Health services aiming at enhancing patients’ accessibility to health professionals, as well as supporting remote monitoring, will be part of the program. Moreover, an open interoperability platform supporting adaptive case management across healthcare tiers and different providers will be implemented to support the service.


 

Programme:

  • Collaborative self-management services promoting healthy lifestyles: physical activity AISBE

Target Group:

  • People in need of physical activity promotion
physical-activity

This is a community‐based service to promote physical activity (PA) in the healthcare sector of Barcelona‐Esquerra (AISBE). It seeks to show that tailored self‐management programmes with remote professional support can induce behavioural changes sustained over time leading to healthier life styles. The programme covers the following items: i) Workflow design of the PA service engaging both patients and health professionals; ii) Definition and development of ICT requirements; iii) Development of an evaluation strategy based on PDSA iterative cycles including collection of structured indicators; and, iv) Deployment of the novel service in the healthcare sector including innovative reimbursement incentives.

The goals of this novel PA service are twofold: i) To generate sustained enhancement of PA with an impact on health‐related quality of life in chronic patients; and ii) to have a cost‐effective impact on multi‐morbidities in terms of preventing occurrence. The outcome will be a roadmap to assess novel collaborative self‐management PA services in an urban health sector of Barcelona (300,000 citizens).


 

Programme:

  • Integrated care for subacute and frail older adults (PSPV)

Target Group:

  • Subacute and frail older adults
frail-older-adults

Parc Sanitari Pere Virgili (PSPV) is the largest monographic geriatric post- and sub-acute resource in Catalonia, Spain. It is the reference facility in Catalonia for acute admission avoidance of older adults with flared-up chronic diseases or minor events superimposed to complex conditions such as dementia, and at risk of unnecessary hospitalisations. PSPV promotes admission avoidance thorough integrated care pathways which allow direct admission from the Emergency Department of two major University Hospitals in Barcelona (Vall d’Hebrón and Clinic University hospitals), and from reference primary care areas.