Region of Southern Denmark

Northern Ireland

Northern Netherlands - Groningen

Basque Country

Catalonia

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Region of Southern Denmark


 

Programme:

  • Centre for Telepsychiatry

Target Group:

  • Citizens eligible for telepsychiatric treatment
telepsychiatry

The Region of Southern Denmark (RSD) has a Health Agreement with its 22 municipalities that focuses on cross-sector treatment involving access to telehealth solutions. It states that emphasis should be placed on citizens in need of psychiatric treatment regardless of their social status.
The Centre for Telepsychiatry at the psychiatric department in Odense is an example of how the Health Agreement is implemented day-to-day. The Centre already has a number of projects in the field of telepsychiatry, i.e. the delivery of psychiatric treatment and expertise at a distance. These include telemedical treatment, telecommunication between the patient, the GP and the psychiatric hospital, as well as between doctors. A joint competence centre is being developed via which knowledge can be shared.
Telepsychiatry has been shown to contribute to improved patient adherence without compromising the quality of treatment.
The Region has dedicated 8 million Danish kroner (more than 1 m €) per year in 2013-2015 to run the centre. Technology such as video conferencing, iPads, ‘The Care Phone’, internet-based treatment and patient apps, enable more targeted and flexible treatment.

In ACT@Scale, RSD will focus on upscaling telehealth treatment for psychiatric patients. This is a priority for the region and by 2019 around 2,000 people will have been offered telepsychiatric treatment.

Northern Ireland

Telemonitoring NI (TMNI) delivers telehealth support to more than 3,000 patients with long-term conditions, helping them to monitor their vital signs at home and empowering them to manage their own health. Telecare provides proactive, support to over 2,700 people. Together, these services give healthcare professionals, patients and service users “fit-for-purpose” integrated healthcare solutions.


 

Programme:

  • COPD Telemonitoring services

Target Group:

  • COPD patients
               copd-telemonitoring

Monitoring of COPD patients using TMNI has been applied particularly well. Specialist respiratory nurses and physiotherapists who were early adopters of the service have reaped benefits in terms of their caseloads and practice development. Monitoring of COPD is a “triage” model where patients monitor daily. Care provided for patients using telemonitoring is more patient-centred.

The aim is to explore how the triage model can transfer to larger target groups as well as across locations, to explore how telemonitoring can benefit patients with mild / moderate COPD, and the effectiveness of a “track and trend” model in enhancing self-management.


 

Programme:

  • Diabetes Telemonitoring services

Target Group:

  • Diabetes patients
diabetes-telemonitoring

Regional teams use telemonitoring for people with Type I diabetes with poor control on insulin or other injectables and Type II clients on insulin or oral medication and GLP-1, as well as women with gestational diabetes.

The ability to identify patterns in blood glucose monitoring helps practitioners. The system encourages patients to monitor more regularly.

The aim is to explore how telemonitoring can better support patients to self-manage. Patients with diabetes transitioning to adulthood are a target population poorly served by current healthcare models. Telemonitoring helps explore more holistic patient management, including diet, exercise, and hypo treatment.


 

Programme:

  • Weight Management Telemonitoring services

Target Group:

  • Women with BMI over 39

weight-management-telemonitoring

Telemonitoring is being used as part of the “Weigh to a Healthy Pregnancy” regional initiative to manage maternal obesity. All consenting women with a BMI >40 are referred. Patient-focused care is at the core of maternity services and weight management, and feedback has been excellent in terms of self-monitoring being a significant motivational tool. Preliminary results from the evaluation team are very positive regarding outcomes. The aim is to explore how telehealth can support and motivate self-monitoring for patients with weight-related conditions.

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.

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.