European Innovation Partnership on Active and Healthy Ageing
EIP AHA
Action Group B3
Integrated Care
Dr. Toni Dedeu
Chair - EUREGHA
Senior International Officer
European Regional and Local Ministry of Health of Catalonia
Health Authrities Association
Istanbul, 10th September 2013
European Innovation Partnership on Active and Healthy Ageing
B3 ACTION GROUP
ON INTEGRATED CARE
EFPC – ISTANBUL 10 SEPTEMBER 2013
European Innovation Partnership on Active and Healthy Ageing
How many of you have ever heard about
EIP AHA?
Are your organisations involved in any EIP
Action Group?
European Innovation Partnership on Active and Healthy Ageing
B3: INTEGRATED CARE COLLABORATIVE
AN OVERVIEW
Ageing society
Lack of health
professionals
Chronic
conditions
Financial
challenges
HLY vs LE
Health
inequalities
HEALTH IN EUROPE 2020
EUROPE 2020 FLAGSHIPS FOR SMART, SUSTAINABLE AND INCLUSIVE GROWTH
Digital
Agenda
New
Industrial Policy
Innovation
Union
Digital Agenda
for Europe
Youth
on the Move
New Skills
and New Jobs
Innovation
Union
Platform against
Poverty
Resource
Efficiency
• innovation for tackling societal challenges, e.g. ageing and health
• innovation for addressing the weaknesses & removing obstacles in the European
innovation system
• ICTs for tackling societal issues - ageing, health care delivery
• sustainable healthcare & ICT-based support for dignified & independent living
EUROPEAN INNOVATION PARTNERSHIP ON
ACTIVE AND HEALTHY AGEING
+2 Healthy Life Years by 2020
Triple win for Europe
Sustainable &
efficient care
systems
health &
quality of life
of European
citizens
growth &
expansion of
EU industry
Action Groups
Better management of health:
preventing falls (A2)
Preventing functional decline and frailty
(A3)
Integrated care for chronic conditions, inc.
telecare (B3)
ICT solutions for independent living & active
ageing (C2)
Age-friendly cities and environments (D4)
Reference Sites
Improving prescriptions and adherence
to treatment (A1)
ACTION GROUPS
EIP AHA
A1
A2
A3
Improving prescriptions and
adherence to treatment (A1)
Better management of
health: preventing falls (A2)
Preventing functional
decline and frailty (A3)
B3
C2
D4
Integrated care for chronic
conditions, inc. telecare (B3)
ICT solutions for independent
living & active ageing (C2)
Age-friendly cities and
environments (D4)
Political added value of the EIP
inspire for policy action
support from the ground
identify good practices working in real life
Joint Action on Chronic Diseases and
Healthy Ageing (28 countries + 5
networks)
High level conferences (e-health, Gastein
Forum, Conference of Partners, Frailty
and Adherence Conferences)
EC: facilitator & supporter
develop policy on active & healthy ageing
align policy priorities with funding
mobilise efforts & resources
Alignment of priorities in Horizon 2020,
CIP 2013, PHP 2013 etc.
Reflection process of the MS: Towards
modern, responsive and sustainable
health systems
POLITICAL ADDED VALUE OF THE EIP AT A
REGIONAL LEVEL
PERSONACTI
VEAGEINGCIT
IZENHEALTHY
OPPORTUNITY
EUROPEAN
CATALONIA COMMISSION
STRATEGIC IMPLEMENTATION PLAN FOR
AHA
EIP AHA
A1
A2
A3
B3
2013
C2
D4
C
RS
OM
Commitment / Reference Site
/ Market Place
14
Building up EIP scale and critical mass
1,000 regions &
municipalities
1 billion euro
mobilised
30 mio citizens,
>2 mio patients
> 500 commitments
3,000 partners
Marketplace
>30,000 visits >650
registered users
Invitation For Commitments 2013
120
100
80
60
108
40
69
36
39
A1 Prescription
and Adherence
A2 Falls
prevention
20
25
34
0
A3 Prevention of
Functional
Decline and
Frailty
B3 Integrated
Care
C2 Interoperable
Independent
Living
D4 Age-Friendly
Environments
Stronger network of partners
-
10 submissions expand existing commitments
30 submissions involve existing AG member
Focus on Implementation
-
close to half of the committed organisations are care providers
over half of the commitments are directly contributing to the implementation of integrated
health and care systems
European Innovation Partnership
on Active and Healthy Ageing
B3 Action Group
‘Replicating and tutoring integrated care for
chronic diseases, including remote
monitoring at regional level’
B3 Objective (Operational Plan 11/11)
• Reducing avoidable / unnecessary
hospitalisation of older people with chronic
conditions, through the effective
implementation of integrated care
programmes and chronic disease
management models that should ultimately
contribute to the improved efficiency of
health systems.
WHAT SOME ‘BRAINS’ SAY ABOUT
INTEGRATED CARE
System Integration
Organisation
Integration
Financial
Integration
Professional
Integration
Service
Integration
Person
al
Integra
tion
Micro Level
Meso Level Macro Level
Population
Based
Person
Focused
Care
Normative
Integration
Personal
Integration
B3 Integrated Care Collaborative
Regions, delivery organisations, patient / carers organisations, academia, industry
iterative,
flexible
process
provide input –
expertise, best
practice
collect experience, evidence
to support policy-making
inspiration
synergies
scale up
innovative
solutions
+2 HEALTHY LIFE YEARS by 2020
A triple win for Europe
B3 ACTION GROUP
MEMBERSHIP
135 EIP commitments received from:
CAT
• Regions
• Delivery organisations
• Patient / carer representative organisations
• Academia
• Industry
199 individual
stakeholders from
committed regions / organisations and growing……
12
19
EIP AHA
INTEGRATED CARE
From Chronic
Care
2020
2013
Integrated
Care
CORE TOPICS
INTEGRATED CARE
YOUR
IDEAS
WAIT
AND SEE
?
EIP AHA
ACTION AREAS
CHALLENGES TO THE
SUCCESSFUL ADOPTION OF
INTEGRATED CARE
What kinds of
PAYMENT SYSTEMS
best incentivise IC
¿
?
Which
ORGANISATIONAL
SOLUTIONS are
more effective
CHALLENGES TO THE
SUCCESSFUL ADOPTION OF
INTEGRATED CARE
How can care be
BETTER CO-ORDINTED
around people’s needs
¿
?
What IMPLEMENTATION
STRATEGIES are likely
to be most effective to
STIMULATE CHANGE
Strategy
Inn
ova
tion
ustainability
POLITICAL ADDED VALUE OF THE EIP AT A REGIONAL LEVEL
PERSONACTI
Op
EU
por
Initi
VEAGEINGCIT
tun
ave
IZENHEALTHY
ity
Predictive
models
Collaborative approach
European Innovation Partnership on Active and Healthy Ageing
B3: INTEGRATED CARE COLLABORATIVE
B3 DELTA QUESTIONNAIRE ANALYSIS
THE DELTA
QUESTIONNAIRE
• Objective:
Gain insights in the implementation of integrated care
• Who:
- Regions / delivery organisations with B3 commitments
- Candidate EIP Reference Sites
• What:
– 27 European regions
– Coverage of population of c. 54 million people
– Spending of > €15 B per annum on care for people
with chronic conditions.
27 REGIONS
FROM EUROPE
KEY FINDINGS OF THE
DELTA QUESTIONNAIRE
SHIFT TO
PRIMARY/COMMUNITY BASED
CARE
USE OF
THE DELTA QUESTIONNAIRE
• Validating the Definition of Integrated Care for the
Action Plan
• Validating and mapping of Action Areas
• Mapping
• Mapping
activities
gaps
The work is on-going:
• Further insights to be gained through B3 activities in
different Action Areas
• Lessons learnt
PERSONACTIV
EAGEINGCITIZ
FOOD
FOR
THE
ENHEALTHYA
DEBATE
GEINGEUEIPA
HAINTEGRATE
DEBATE
B3 ACTION AREAS
PERSONACT
risk
stra
VEAGEINGC
tific care
path
TIZENHEALT
tion
ways
workf
orce
devel
opme
nt
financing
organisational
models
patient/user
empowerment
dissemination
B3 ACTION AREAS
PERSONACT
VEAGEINGC
TIZENHEALT
AA1 Organisational Models
AA2 Change Management
AA3 Workforce Development
AA4 Care Pathways
AA5 Risk Stratifiction
AA6 Patient/User Empowerment
AA7 ICT
AA8 Financing
AA9 Dissemination
EIP AHA B3 Action Plan
Increase the average number of healthy life yrs by 2 in the EU by 2020
Health status and quality of life । Supporting the long term sustainability and efficiency of health and social systems । Enhancing competitiveness of EU industry
Chronic Conditions
By 2015
Chronic Conditions’ Programmes available at
least 10% of target population in at least 50
regions
Integrated Care
By 2015 - 2020
SIP
TARGETS
Integrated Care Programmes serving older people,
supported by innovative tools and services, in at least
20 regions
Action Area
Action Area
Action Area
Action Area
Action Area






Organisational
Models
Change
Management
Workforce
Development
Risk Stratification
Care Pathways
Patient / User
Empowerment
Map of partnership
models for
implementation of
Chronic and
Integrated Care
Programmes
Map of best
practice
methodologies to
support the
implementation of
Chronic and
Integrated Care
Map of
reusable learning
resources
Stratification of
the population
Mapping Best
Practices in the EU
regions
Toolkit
Toolkit
Toolkit
Toolkit
Toolkit
2013
Monitoring impact and outcomes
Map of coaching,
education and
support
patient/user
empowerment
and adherence
Toolkit
2015
Toolkit
Action Area
Toolkit
Finance/Funding

ICT Tools


Dissemination
Action Area
Action Area
Action Area
Implementation and Scale Up of Chronic Care + Integrated Care Programmes
4
STRATEGY
Map
ping
• How?
Desktop
search
• Method?
Good
Pratices
• Analysis From
Commtments
EU
projects
• Analysis
Other
sources
• Analysis
STRATEGY
Map
ping
• Collecting
info
Analy • How?
sis
Toolk • SCALE
UP
it
European Innovation Partnership on Active and Healthy Ageing
B3: INTEGRATED CARE COLLABORATIVE
B3 GOOD PRACTICES
B3
GOOD PRACTICES
• Objective: to gather an initial map of current
integrated care activities relating to the B3
Action Areas
• Who: All B3 members were invited to
complete the B3 Good Practice template
• What: 37 regions / organisations completed
the template by the end of April 2013
COLLECTION OF GOOD
PRACTICES
MARCH-APRIL 2013
• 37 good practices
SEPTEMBER 2013 > 50
• 29 organisations
• 16 regions
• 8 action areas
… and the collection
is still on-going
THEMATIC COVERAGE OF THE GOOD
PRACTICES
B3 ACTION AREAS
14
13
14
Relevant good practices
12
11
11
10
8
7
8
6
3
4
3
2
0
AA1
AA1
AA2
AA3
AA4
AA2
AA3
Organisational Models
Change Management
Workforce Development
Risk Stratification
AA4
AA5
AA6
AA7
AA8
AA5
AA6
AA7
AA8
Care Pathway
Patient / user empowerment
Electronic Care Records / ICT / Teleservices
Finance, Funding
COVERAGE OF THE
GOOD PRACTICES
14
12
10
8
6
4
2
0
under 10,000
10,000-50,000
50,000-1000000
over 1,000,000
N/A
- Size of the target population varies from 50 patients to 7.5
million citizens
- Total: over 13 million people
THEMES
SEMEH
50% of the good practices target one or
more chronic disease (cardiovascular
diseases, COPD, diabetes, etc)
Numerous examples of comprehensive
regional programmes for chronicity
Wide range of issues, incl. insurance, social
security, housing, independent living,
volunteering, impact on competitiveness
Innovation in technologies, delivery of
services and organisation
Patient-centered
Strong focus on implementation
AND …..
A FEW EXAMPLES
ParkinsonNet, Radboud University Nijmegen Medical Centre
Successfully improved Parkinson care in the Netherlands by:
1.
2.
3.
4.
Developing regional networks of primary and secondary Parkinson care around general
hospitals
Selecting and training physiotherapists to work according to evidence-based guidelines
Boosting patient volumes per therapist by stimulating selective referral to ParkinsonNet
therapists
Supporting these networks with online tools to enhance information exchange and
communication and therefore collaboration between allied health professionals, neurologists,
and empowered patients.
The model demonstrates:
1.
2.
3.
4.
An improvement in the quality of care for those patients
Prevention of disease complications (including a 50% reduction in hip fractures)
A reduction in hospitalization
A substantial cost reduction (€20 million annually in the Netherlands alone)
SUSTAINABILITY
GOOD PRACTICE IN AA7
ICT AND TELESERVICES
NHS24, Scotland: ICT for prediction of risk improves planning
healthcare and better address of resources .
Puglia, Italy: Telecardiology - Over 550.000 ECG performed,
significant
reduction of avoidable death, 60% underwent
appropriate treatment and no hospitalization unless urgent (only
11%)
Lombardia, Italy: Homebase telesurveillance programme COPD
patients. 60% of patients didn’t occur hospitalization.
Fondazione B.Kessler Trentino, Italy: Access to personal HER a
key element for empowerment. Best practice in the field of
Public-Private partnership for e-health procurement
GOOD PRACTICE IN AA7
ICT AND TELESERVICES
NHS24 Scotland: ICT to support learning network – to share knowledge
and foster peer to peer review.
Catalonia NEXES Project: ICT Platform for health information sharing,
Patient self-management, Electronic Health Record.
Basque Country TelBil: ICT telemonitoring resulted in significant
reduction in hospital admissions for patients with Heart Failure and COPD
Saxony, Germany: ICT for Diabetic patients, management of patients
data, networking among stakeholders, real time monitoring of related
costs
Lombardia Fondazione Maugeri, Italy: Telesurveillance programme for
Heart Failure patients demonstrated reduction of hospitalisation and
improved access to appropriate care
SIPE, Emilia Romagna, Italy: R.A. financed Industrial District, creating
partnership between enterprises and Universities to foster R&D processes
followed by technology transfer
NEXT
STEPS...
• An analysis of good practices will be
undertaken to determine:
– Success factors – why initiative worked well
– Lessons learned – what didn’t work / what could
be done better / differently
– Transferability to other regions / organisations – to
promote scale up of integrated care
• Will inform the development of the B3 toolkits
European Innovation Partnership on Active and Healthy Ageing
B3: Integrated Care Collaborative
Action Area 7: ICT and Teleservices
B3 ACTION AREA 7
ICT AND TELESERVICES
 Objectives/activities
 Highlight the potential of ICT/teleservices to underpin the
delivery of integrated care and to realise service
efficiencies/cost-effectiveness (Action Plan, 2012)
 Improve the effectiveness of health and social care ICT
systems and data sharing by identifying solutions which
improve interoperability between record systems and data
sharing (Action Plan, 2012)
B3 ACTION AREA 7 DELIVERABLES
Mapping of ICT solutions
Electronic care records
Personal health records
Aligning existing projects (epSOS, Calliope)
Common security processes (identification, authentification, authorization and patient consent)
Teleservices
Increased levels of integration of clinical and social data
Increased implementation of electronic consent and share record capabilities
Availability of functionality in Electronic Health/Care Record
Toolkit for Electronic Care Records/ICT/Teleservices:
Approaches to managing regulatory issues, security, privacy, liability, confidentiality and
interoperability
Reductions of risk and time to market costs for industry
Model business cases to support implementation and scale up
European Initiative Service Specification for the development of personal digital health records
Increased implementation of teleservices as part of Integrated Care Programmes
B3 ACTION AREA 7
WORK PLAN FOR 2013
 Work package description WP7-1
 Map of ICT solutions focusing on how services for chronic disease
management or integrated care are being supported by common eHealth
infrastructure
 Task Description T7-1
 T7-1-1 Definition of services for integrated care and chronic disease
management
 T7-1-2 Analyse the compatibility of services with the outcomes of other
existing European projects (e.g. epSOS, Calliope)
 T7-1-3 Validate the outcomes of T7-1-2 through the practical workshop
 T7-1-4 Develop indicators for ICT solutions
 T7-1-5 Evaluate models of ICT solutions supported by common eHealth
infrastructure
TIME TO GET
INVOLVED!
 How can we better utilise ICT /
Teleservices to support and
promote the scale up of integrated
care in Europe?
 How could EIP and the B3 Action
Group help?
TIME TO GET
INVOLVED!
 Are you currently working on the
projects where the outcomes of which
can help to achieve the objectives of
AA7, or AA1, AA2, AA3, AA4, AA5, AA6,
AA8
?
TIME TO GET
INVOLVED!
 In your opinion, what are the services
necessary to support and stimulate the
delivery of integrated care
?
Jean
Thanks from
Cris
tina
PERSONACTI
Bart
VE
AGEINGCIT
Loukianos
Mag Don
na Francesca
da
rian
IZENHEALTHY
Orsi
George
To
ni
European Innovation Partnership on Active and Healthy Ageing
thank you
B3 Action Group on
Integrated Care
Dr. Toni Dedeu
tdedeu@gencat.cat
https://webgate.ec.europa.eu/eipaha/actiongroup/index/b3