Working towards integration: Advancing Care Coordination & TeleHealth Deployment (ACT) Programme

Abstract

Co-ordinated Care (CC) and TeleHealth (TH) services have the potential to deliver quality care to chronically ill patients. They can both reduce the economic burden of chronic care and maximise the delivery of clinical services. The value of TeleHealth services has been highlighted in the Cochrane Review (Inglis et al, 2010) and the COPD Cochrane Review (McLean et al, 2011). Such services require new behaviours, routines and ways of working directed at improving health outcomes, administrative efficiency, cost effectiveness and user (patient and health professional) experience. Translating evidence into practice is complex and requires significant organizational change. Exactly how these services are designed and configured is the subject of the ACT programme. The ACT consortium focus is on 'what works well' and 'how can we make it work better?' It does this by examining twenty sites across four countries in Europe and assessing what is most effective and what the difficulties are in implementing this form of change. The intention is to produce a toolkit for use across Europe. This poster gives a summary of the ACT Programme, the sites participating, diseases covered, numbers of patients, project timetable and the aim to provide a 'toolbox' of best practice. ACT programmes fall within five broad areas: CC of Management of Chronic and Multimorbid longterm conditions; Management of Chronic and Multimorbid long-term conditions with telehealth; Active patient/prevention/Education; Elderly at home; and Transitional care/post discharge. The number of patients recruited to ACT programmes varied considerably, from the small scale (e.g. Scotland's REACT project for those over 75 and Groningen's eDiabetes programme, both with 15- 20 patients) to much larger scale (e.g. Lombardy's Chronic patients with 37,000). Most Programmes (14 out of 17) recruit people with chronic conditions and in some cases these are specified such as Congestive Heart Failure (one programme) and Diabetes (three programmes). Patients in recovery or rehabilitation were the second most cited group (12 out of 17). Patients in the preventative category were least likely to enter Programmes (5 out of 17). Some Programmes accept patients at multiple key stages. For example, Groningen's Effective Cardio Programme accepts patients at the preventative, newly diagnosed, disease management, recovery/rehabilitation, at risk, chronic and palliative stages, in addition to those on new medication. All Programmes reported clear lines of responsibility for the provision of patient care. General Practitioners/Primary Care took responsibility in nine of the 17 Programmes. Elsewhere, specialist nurses held responsibility (e.g. Groningen's Effective Cardio) or chest physicians (e.g. Groningen's asthma/COPD Telehealth service). Other Programmes apportioned responsibility at a broader level via a Programme Management Working Group and local managers (Basque Country's Active Patients) for example, or with a National diabetes standard and regional guidelines (Groningen's eDiabetes) or with defined care pathways (Scotland's three Programmes). Further details of the organisational aspects of the participants in the ACT programme will be presented in the Poster ABSTRACT FROM AUTHOR]; Copyright of International Journal of Integrated Care (IJIC) is the property of Ubiquity Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)