Scale-up 15 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.
People with chronic diseases or mental illnesses, or who are elderly or frail.
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:
- Change management,
- Stratification, inclusion of patients and adaptation of the service,
- Economic model and system sustainability and
- 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.
The work to be done in the project is divided into work packages: project lasting 36 months
- WP1: Project coordination, management and quality control (Month 1 – Month 36)
- WP2: Dissemination (Month 2 – Month 36)
- WP3: Evaluation (Month 3 – Month 36)
- WP4: Good practice transfer and data analysis (Month 1 – Month 36)
- WP5: Stakeholder advisory board and change management (Month 1 – Month 36)
- WP6: Selection of services (Month 1 – Month 35)
- WP7: Sustainability (Month 1 – Month 34)
- WP8: Empowerment of the population (Month 1 – Month 36)
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 103,700 people in all the regions of several European countries.