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Integrated care and ICT to reduce frailty and chronic diseases in ageing women of the CARMEN cohort.

The aim is the reduction of frailty and chronic diseases with strong gender profile, mainly musculoskeletal (osteoporosis) and cognitive decline, through the implementation of healthy lifestyle. Our population is composed of the women entering the cohort Chronic Ailment Reduction after MENopause (CARMEN, 1400 community dwelling women from the urban area of Valencia). Women initiate a program of integrated care, where primary care nurses and social workers act together to perform screening and subsequent monitoring after implementation of a physical activity program. The team also includes specialists in women’s health in the third level hospital. ICT is used to empower participants, whose adherence is stimulated through the use of a mobile phone-based virtual support group. A basic teaching course is given to facilitate use of technology. The tools used for frailty and cognitive decline screening are being shared with other A3 partners as a result of a collaborative work initiated in 2013 in order to strengthen synergy and harmonisation of databases. Further, the commitment is inserted within the Valencia reference site. Clinical and analytical data are kept in a database while serum and ADN samples are stored in biobank. A parallel basic research programme aims at exploring the effects of lifestyle on genomics of bone metabolism and frailty. The fact that the program is developed within the public health system provides conditions for scalability at national and international level.
Background
Geographical scope: 
Regional level
Region involved:
Countries involved:
Organisation
Organisation name: 
University of Valencia- INCLIVA
Organisation address: 
AV BLASCO IBÁÑEZ 17 46010 Valencia, Spain...
Kind of organisation: 
Hospitals
Primary care centres
Specialised physicians
General practioners
Nurses
Research centres
Academia
Viability
Time for deployment: 
Between one year and three years
Preparation of implementation: 
We developed a program integrating primary and specialised care, with the inclusion of physicians and nurses. Once the scheme was set up we completed a series of initiatives to make the program both scalable and evidence-based. Funds at this stage were derived from Asociación Salus Vitae and a...
Investment per citizen / service user / patient: 
Between 100 – 1.000 EUR per targeted citizen / patient
Cost calculation: 
Costs include the salaries of the intervening staff plus the medical explorations.
Evidence of practice: 
Apparent evidence. Evidence is based on qualitative success stories
Evidence creation: 
The impact of our intervention is being assessed qualitatively at the present moment. Studies are ongoing in which strong clinical evidence is being assessed.
Maturity level: 
Proof of concept is available: it works in a test setting and the potential end-users are positive about the concept.
Maturity level detalis: 
The practice is well inserted within the network of the public health system, integrating primary care centres with the specialists in the third level hospital. Also, nurses are integrated with researchers and medical specialists. This warrants scalability to similar models in Europe, which is the...
Time of impact: 
Long term and sustainable impact – e.g. a long time after the pilot project ended and routine day-to-day operation began
Kind of impact: 
Better quality of life (societal)
Aspects time of impact: 
During the progression we have not been able, for obvious reasons, to detect changes in final clinical events, which require a long-term follow up and a huge number of participants. However, even with the still low numbers, we have detected improvement in psychological indicators (mood, social...
Transferability level: 
Transferability has not been considered. The innovative practice has been developed on local/regional/national level and transferability has not been considered in a systematic way
Transferability details: 
The selected option is insufficient to describe our actual status, but we do not fill up the totality of conditions of the second option. In summary, we meet the requirements for transferability because the practice evolves within the common structure of a public health system. Nevertheless, we...
Initiative
Type of Practice: 
Notable practice
Stakeholders concerned: 
Hospitals
Primary care centres
Specialised physicians
General practioners
Nurses
Research centres
Academia
NGOs
Regional public authorities
Local public authorities
Advocacy organisations others
Reach of initiative: 
1,000 - 9,999
Age group: 
50 - 64
65 - 79
80+
Baseline information: 
Healthy ageing has specificities in women. This affects frailty, and functional decline. Physical activity is a lifestyle measure that has demonstrated benefits at physical and psychological level. The difficulty of population programs of physical activity resides in poor adherence. ICT may...
Source of funding: 
European funding
Funding scheme: 
Health Programme