FULL NAME: Advancing Care Coordination and Telehealth (CC&TH) deployment at Scale

CALL FOR TENDER FOR PROJECT: HP-PJ-2015:Support for the implementation and scaling-up of good practices in the areas of integrated care, frailty prevention, adherence to medical plans and age-friendly communities

WEBSITE: www.act-at-scale.eu

COORDINATION OF THE PROJECT: Philips – Home Healthcare Solutions

act-scale-project-eu-good-practiceDESCRIPTION: ACT@Scale is a European project whose aim is to promote scaling-up of good practices in integrated care and telemonitoring, as well as to transfer learning and knowledge on implementation, development and consolidation of good practices to other European regions.

PROJECT AIMS: Scale-up 13 CC&TH programmes, in order to have a real impact on people with chronic diseases or mental illnesses, or patients who are elderly or frail, reducing mortality and improving their quality of life. Osakidetza is taking part with two good practices that will be scaled up: the telemonitoring service for patients with heart failure and the integrated intervention programme for patients with multiple comorbidities.

ADRESS TO: People with chronic diseases or mental illnesses, or who are elderly or frail.

WORK METHODOLOGY: The work methodology is based on cycles of improvement and learning, known as PDSA(Plan, Do, Study, Act), where some areas of these good practices need to improved, such as:

  • 1) Change management,
  • 2) Stratification, inclusion of patients and adaptation of the service,
  • 3) Economic model and system sustainability and
  • 4) Empowerment of patients/citizens.

Yearly data will be collected to evaluate the results of the implementation of the good practices as well as their effectiveness and efficiency.

act-scale-project-euThe work to be done in the project is divided into work packages: project lasting 36 months

  • 1:Project coordination, management and quality control (Month 1 – Month 36)
  • 2:Dissemination (Month 2 – Month 36)
  • 3:Evaluation (Month 3 – Month 36)
  • 4:Monitoring(Month 1 – Month 36)
  • 5:Stakeholder advisory board and change management (Month 1 – Month 36)
  • 6:Selection of services (Month 1 – Month 35)
  • 7:Sustainability (Month 1 – Month 34)
  • 8:Empowerment of the population (Month 1 – Month 36)

TARGETED OUTCOME: The result expected from ACT@Scale is the large-scale deployment and transfer of the existing good practices in integrated care and telemedicine in order to provide care to over 75,000 people in all the regions of several European countries.


  • ROLE OF KRONIKGUNE IN THE PROJECT: Kronikgune is the leader of work package 3, Evaluation (WP3), whose objective is to develop and validate a structured methodology to evaluate, compare and exchange experiences in scaling-up of integrated care and telemedicine programmes. It also collaborates with Osakidetza in the correct development of work package 6, Selection and dynamic adaptation of the service, led by Osakidetza.
  • ROLE OF OSAKIDETZA IN THE PROJECT: Osakidetza participates with two good practices which are also corporate programmes: the telemonitoring service for patients with heart failure and the integrated intervention programme for patients with multiple comorbidities. It is also leader of work package 6, selection of service, which includes stratification, inclusion of patients and adaptation of the service, which strives to optimise resources according to the changing needs of the population. The aim of this work package is to reach an appropriate level of distribution of healthcare resources to respond to the needs of the patients and populations.


  • Coordination: Danika Schepis; Anna Giné March (till November 2016); Ane Fullaondo; Esteban de Manuel Keenoy.
  • Core: Igor Zabala Rementería (PI); Guillermo Alcalde Bezhold; Nerea Aperribay Sáez; Julia Barroso Niso; Ariadna Besga Basterra; Antonio de Blas; María Victoria Egurbidea Beras; Francisco Javier Fresco Benito; Marbella García Urbaneja; Begoña Gómez Bravo; Rosa González; Rosa María González Llinares; Gabriel Inclán Iribar; María Luz Jauregui; Jesús María Larrañaga Garitano; Mari Luz Marqués González; Marisa Merino Hernández; Nekane Murga Eizagaecheverri; Isabel Rodríguez Fuentes; Raquel Roca; María Isabel Romo Soler; Arantxa Urruzola Lizarribar and new additions pending confirmation.


  • IHO Tolosaldea
  • IHO Ezkerraldea-Enkarterri Cruces
  • IHO Barrualde – Galdakao
  • IHO Bilbo-Basurto
  • IHO Uribe
  • IHO Donostialdea
  • IHO Goierri – Alto Urola
  • IHO Bidasoa
  • IHO Alto Deba
  • IHO Araba
  • IHO Debabarrena
  • Santa Marina hOspital
  • Gorliz Hospital
  • Health Council 
  • SIAC