Action Group B3: Integrated Care
The main targets of the Group are:
- By 2015 making programmes available for the case management of chronic conditions (including remote management and monitoring) serving older people in at least 50 regions, and available to at least 10% of the target population (patients with chronic diseases).
- The scale-up and replication of integrated care programmes serving older people, supported by innovative tools and services, in at least 20 regions in 15 Member States based on validated, evidence-based cases (2015-2020).
- Knowledge sharing about the delivery of services for chronic conditions management in an integrated way and about incentive schemes in this field across Europe.
- Shared understanding of the workforce development task at the European level.
The detailed Action Plan 1023 KB is structured into 9 working areas: organisational models; change management; workforce development;risk stratification; care pathways; patient empowerment; electronic care records/ICT/Teleservices; finance and funding; and communication and dissemination.
The expertise of the Group is reflected in a rich collection of 86 good practices 4.1 MB as well as a set of resources, collected throughout 2013.
members are working together to develop practical tools that support local
- A maturity mapping to identify existing organisational models and detect the success factors of managing structural changes towards integrated care.
- Validated medical guidelines in respiratory and cardiovascular diseases, with the goal of replicating them in their countries, have been developed by a collaboration of hundreds of health professionals, public authorities and patient organisations.
- Experts have collected and started to analyse tools for the risk stratification of the population for optimised and targeted care, and make these available for organisations that are planning to develop or improve their systems.
- The ICT Service Matrix, a reference document that characterizes the different types of services in an integrated health and care information infrastructure.
powerful driver of the Group is the shared vision of integrated health and
social care services that centres around the patients and their community:
the work on citizen empowerment has helped develop a common understanding as a
basis for on-going work with non-members experts.
The Action Group is
keen to work transversally. An example of this approach is the organisation of
workshops on innovative procurement and interoperability together with the
Action Group C2 on Interoperable Independent Living Solutions. The Group
provided input to EU funded projects.
Local implementation is both the
foundation and aspiration of the work of the Action Group, which supported a
number of regional and international events that have successfully mobilised
support for integrated care, resulting in access to additional funds. The
members have forged successful coalitions for the replication of their
practices in new regions and in new areas. In addition, by providing evidence
and inspiration for policy making, the Group has contributed to ensuring that
integrated care is on the European agenda as one of the most promising solutions
to assure the
sustainability of the systems for health and social care.