• FULL NAME: Multi-level integration for patients with complex needs.

  • CALL FOR TENDER: CIP-ICT Policy Support Programme 2013-7

  • TIME FRAME:  01/02/2013 to 31/01/2017

Mainly focussed on improving care and care services for complex chronic patients (multiple co-morbidities) by two routes: coordination and communication between healthcare professionals and empowering the patient and/or caregiver, and home-based care and support based on the use of information and communication technologies (ICT). This will allow patients or their caregivers to communicate with the doctor or advice centre using methods that do not require the patient to attend the health centre.

The aim of Carewell is to propose, implement and validate new integrated care models for patients with multiple comorbidities that are cost-effective, using different routes, such as improving home-based patient care, thereby preventing their hospitalisation, and improving communication channels between (healthcare and social) professionals and patients and/or care models to facilitate the exchange of information for each patient, thereby avoiding duplication of effort.

Divided into work packages – project lasting 36 months.

  • 1: Project coordination, management and quality control (month 1-month 36).
  • 2: Integrated care programmes: User requirements and definition of use cases (month 1-month 9).
  • 3: Definition of organisational models and Carewell care routes (month 2-month 10).
  • 4: Definition of the technological architecture and service specifications (month 2-month 11).
  • 5: Preparation of the pilot phase (month 4-month 12).
  • 6: Intervention implementation phase (month 3-month 36).
  • 7: Results evaluation and application of predictive modelling (month 2-month 36).
  • 8: Dissemination activities and viability analysis (month 1-month 36).

  • An improvement in patients’ quality of life.
  • The provision of effective and cost-efficient solutions.
  • To promote the creation of a richer and more decisive professional experience.
  • To improve cooperation and communication between professionals for the patient’s benefit.
  • To promote integrated care programmes in new regions.
  • To provide new evidence for integrated care outcomes in a real context.
  • To increase awareness of the impact and benefits of integrated care.
  • To promote the use of technology in integrated care.
  • To provide organisational tools and models that allow the development and implementation of integrated care.
  • ROLE OF KRONIKGUNE: Kronikgune coordinates the project at a European level. In addition, it leads work package 3 (WP3), which aims to define organisational models and care routes at a European level. In the regional context, Kronikgune collaborates in the definition and promotes the roll-out of the intervention in complex chronic patients (multiple co-morbidities), and also leads the patient empowerment programme, including developing the contents and materials required for the intervention. 
  • ROLE OF OSAKIDETZA: Leads working package 4 (WP4), which focuses on defining the technological architecture and technical specifications at a European consortium level. In addition, it will implement the pilot phase in the Basque Country, which will commence in 2015, by enrolling 100 complex chronic patients (multiple co-morbidities) from IHOs in the Basque Country, with an intervention period of 12 months. 
  • Coordination: Ane Fullaondo Zabala; Anna Giné March (till November 2016);  Sara Ponce Márquez (till March 2016), Lola Verdoy Berastegui, Irati Erreguerena Redondo, Joana Mora Amengual (till October 2015), Esteban de Manuel Keenoy.
  • Principal: Mª Luisa Merino Hernández (IP); Andoni Arcelay Salazar; Alfonso Casi Casanellas; Mª Victoria Egurbide Arberas; Ángel Faría Rodríguez; Francisco Javier Fresco Benito; Marbella García Urbaneja; Nicolás Francisco González López; Gabriel Inclán Iribar; Mª Luz Marqués González; Jose Manuel Martínez Eizaguirre; Miguel Ángel Ogueta Lana; Ana María Porta Fernández; Raquel Roca Castro; Isabel Rodríguez Fuentes; Igor Zabala Rementeria. 
  • Collaboration: María Nerea Aperribay Saez; Cristina Domingo Rico; Beatriz Inocencia Morcillo Del Pozo; María Delfina Riveira Fernandez; María Isabel Romo Soler; Iraide Sarduy Azcoaga; María Olga Tellechea Rodriguez.
  • Evaluation: Javier Mar Medina; Myriam Soto Ruiz de Gordoa; Itziar Vergara Mitxelena. 
  • OSI Bilbao-Basurto
  • Hospital de Santa Marina
  • OSI Barrualde-Galdakao
  • OSI Ezkerraldea-Enkarterri Cruces
  • OSI Tolosaldea
  • OSI Uribe
  • OSI Araba

Apulia (Italy), Veneto (Italy), Zagreb (Croatia), Lower Silenia (Poland) and Powys, Wales (UK), Basque Country (Spain).