You may access it for free on the project’s official website.

The Handbook gathers the experiences and results of the three-year study. It intends to spread knowledge and share the experiences of the regions participating in the study of good practices in integrated care and telemonitoring. These Good Practices are aimed at patients suffering from chronic diseases or mental illnesses, and elderly or frail people. The goal of the guide is to contribute to transfer knowledge in Europe and beyond.

The handbook describes in detail the work that has been developed by each of the participating regions of the European project to develop, consolidate, and scale-up innovative practices through collaborative methodology or “PDSA–Plan, Do, Study, Act”. Similarly, it shows the efforts developed by the regions to benefit European citizens and includes the knowledge acquired on factors that have been identified as crucial in the scaling-up of good practices. These factors are: Choosing services; Management of stakeholders and change management; Sustainability and business models; and Patient and/or citizen empowerment. It also includes fact sheets on the best programmes that have been scaled-up and implemented within the framework of the project.

The Basque Country features the work developed by multidisciplinary teams to improve two of Osakidetza’s corporate programmesThe pathway for integrated care of multimorbid patients and the telemonitoring service for heart failure patients. Multidisciplinary teams made up of managers and health professionals from all of the Osakidetza Integrated Healthcare Organisations (IHOs), Gorliz Hospital, Santa Marina Hospital and Osakidetza Health Council and Central Services have been involved in this work for months. They expect to extend both programmes to the other organisations within the Osakidetza.

If you want to learn more about this project and the experiences of the regions participating in ACT@Scale, and more specifically the experience of the Basque Country, download the handbook here: