Policy Context and Legal Framework

The services foreseen in the project operate under the legislation of each of the member states. Diversity of these frameworks will be explored during the project phase. Some grey areas regarding shared responsibility among professionals will also be studied.

NEXES will be developed at a European level in 3 areas (central Norway, Athens and Catalonia). In Catalonia, the project management monitoring (NEXES- Living Healthily at Home) will be done by a commission appointed by the Health Department of the Catalan Autonomous Government.

One of the important objectives of the project is to identify leadership qualities in Catalonia in order to stimulate territorial expansion of innovative integrated care services as validation results continue to be generated. We hope to establish collaborations with other Spanish autonomous governments. At a European level, the Linkcare Alliance will also stimulate these types of dynamics.

Implementation and Management Approach

The delivery model assumes that integrated care provides a more efficient approach due to four reasons:
- The normalisation of the interventions as opposed to traditional care (where at each contact it is decided what comes next) facilitates a new organisational frame. The set of interventions are geared towards specific health and/or social goals, generally more specific than those adopted in traditional care (i.e. improving patient self-management of the disease versus improved clinical outcomes)
- The redefinition of the roles of professionals: given the precise definition of patient trajectories, checkpoints can be incorporated and, accordingly, delegate in nurses or other professionals, regular follow-up activities.
- Generation of opportunities for a more proactive allocation of scarce resources. It is possible to anticipate the resources that will be needed to attend the majority of the patients (80%) and, as a result, also foresee the needed free time for those requiring traditional approaches
- The model results in higher needs of coordination and information sharing among professionals, not only belonging to different specialties, but also across different teams and providers. This is where the ICT solutions enter the picture. Its value lies on their capabilities of enabling these interactions to take place.

Technology solution

Technologically, the Linkcare platform (Linkcare eTEN 517435) sets the reference architecture. Modularity, flexibility and scalability are based on Service Oriented Architectures (SOA) using the IBM UML 2.0 Profile for Software Services.

Briefly, the platform consists of a web-based application addressed to management of chronic patients and elderly, facilitating organizational interoperability following a distributed model.

The following services are available at the moment:
- Health portal,
- Call centre service,
- Professional mobile access,
- Patient wireless monitoring service,
- Collaborative work service,
- Security modules
- Interoperability module with hospital information systems and shared electronic patient records.

In the future, it will incorporate knowledge management applications and it is foreseen its evolution towards an IMS platform.

Impact

Innovation relies on the interplay of three factors:
- adoption of an integrative approach including profound organizational changes,
- facing the co-morbidity challenge,
- use of ICT as modular and scalable tools supporting interoperability among actors.

The main programs of the project are:
- Wellness-rehab: Early diagnosis, promotion of healthy life-styles and patient self-management. Physical activity and cognitive aspects being main components;
- Enhanced Care Support of unplanned hospitalizations;
- Home hospitalization of patients with exacerbations;
- Support: Transient remote support to diagnosis and/or treatment

Track record of sharing

Health authorities in the different sites are already present in the project Consortium thus ensuring positive commitment beyond the pure project life. Thus, in Catalonia, the involvement of the Department of Health illustrates a willingness to go even further: Around Nexes, the commission for innovation of the Department of Health is working to take the service model to primary care practices.

Lessons learnt

Lesson 1 - Evolution from pilots to services for the programes considered in the project.

Lesson 2 - Controlled deployment, integration and validation of services

Lesson 3 - Identification of strategies suitable for the success of extensive and sustainable deployment of services