The Basque Country, represented by Kronikgune and Osakidetza, leads the European Carewell project, which mainly focuses on improving the care and care services provided to multiply co-morbid patients via two pathways: the coordination of integrated care, and empowerment, care and support at home by way of the development and use of new information and communication systems (ICTs).

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 pathways, such as improving home-based patient care, thereby preventing their hospitalisation, and improving communication channels between (healthcare and social) professionals and patients and/or caregivers to facilitate the exchange of information for each patient, thereby avoiding duplication of effort. 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 importance of empowerment of the patient and/or caregiver within this project should be highlighted as they will be educated in their disease and in how to recognise the symptoms. This, together with the use of telemonitoring systems and advice centres, will allow medical staff to perform a better follow-up of the patient’s evolution.

The new attention and care pathways for the chronic and multiply co-morbid patient will be piloted at a European level in eight countries. Thus, a 12-month pilot study will allow new integrated care pathways to be specified, developed and rolled-out in the Basque Country, Apulia, Veneto, Wales, north-west Croatia and Lower Silesia (Poland).

This European project forms part of one of the strategic lines of the Department of Health and Osakidetza that has been worked on since 2009 and in which chronicity, ageing and dependency is one of the key priorities. The work conducted has led to a continual and progressive transformation in the healthcare model in the Basque Country, which has resulted in an improvement in the care, quality of life and health outcomes for these patients while allowing a greater sustainability of the healthcare system. Over the past few years Osakidetza has incorporated tools such as interconsultations, telemonitoring, the Health Dossier, the active patient portal and follow-up calls, which help to achieve better coordination between professionals, more frequent monitoring of the patient’s health status and an increased participation of patients in the management of their disease.

Call for tender for project: CIP-ICT Policy Support programme 2013-7

To learn more about this project visit the official web site: