• FULL NAME: Care Coordination &TeleHealth Deployment Programme

  • CALL FOR TENDER: Health Programme 2012, Directorate General for Health and Consumer Affairs (currently CHAFEA)

  • TIME FRAME: 15 February 2013 to 15 June 2015

To identify best practices in organisational and structural care integration support processes and the application of telemedicine in a healthcare coordination context for the routine management of chronic patients. The consortium will investigate the organisational and structural keys in five European healthcare regions and these keys will subsequently be perfected by the participating regions and a group of the leading European experts in CC&TH. The study will focus on the management of groups with heart failure, COPD, DM and co-morbid patients, with a minimum of 300 patients per region.

To optimise the structures, workflows and the organisation of care coordination and telemedicine, and to identify patient stratification tools that are accurate and easy to use.

Divided into work packages – project lasting 26 months.

  • 1: Project coordination, management and quality control (month 1 – month 26).
  • 2: Dissemination (month 1 – month 26).
  • 3: Evaluation.
  • 4: Optimisation of the organisation of care coordination and telehealth and of work process structures.
  • 5: Patient stratification.
  • 6: Improvement in patient adherence and the commitment of professionals.
  • 7: Improvement in care efficacy and efficiency.
  • Increase the commitment and education of healthcare professionals.
  • Improve care efficacy and efficiency.
  • Improve patient adherence.
  • Improve health outcomes.
  • ROLE OF KRONIKGUNE: Currently coordinating the compilation of qualitative information from healthcare professionals and patients and organising the focus groups. Kronikgune is analysing the quantitative information received as a result of a collaboration with the Osakidetza’s IT Subdirectorate. Kronikgune is also responsible for all communications and for managing the European consortium.
  • ROLE OF OSAKIDETZA: Together with Kronikgune, Osakidetza is analysing the Integrated Intervention Plans (IIPs) for all Integrated Healthcare Organisations (IHOs) in the Autonomous Community of the Basque Country. Quantitative information, namely health indicators for 2012 and 2013 for all IHOs, and qualitative information based on questionnaires for both healthcare professionals and patients, is being compiled to undertake the analysis, and a focus group is being organised for patients from the IHO Barrualde – Galdakao.
  • Coordination: Sara Ponce Márquez; Eva María Ramos Saiz (till June 2015); Joana Mora Amengual (till October 2015); Esteban de Manuel Keenoy.
  • Principal: Cristina Domingo; Estibaliz Gamboa y Jon Orueta (IP).
  • Collaboration: Manuel Carneiro.