Remote monitoring of health

Action Group
B3 - "Replicating and tutoring integrated care for chronic diseases, including remote monitoring at regional levels"
Back to Action Groups
General objective

Reduce the number of unnecessary / avoidable hospital visits by elderly people with chronic illnesses. Undertake the effective implementation of integrated programs for geriatric assistance and chronic disease management models in order to help increase the efficiency of health systems.

Specific objectives

Models of organisation – regional expansion of integrated social work and healthcare programs

  • Optimisation in management - promotion of public policies and regional resource management within health, economic and social political sectors in order to optimise the response of the systems and the quality of care:
    • a) ensure support for integrated care policies;
    • b) enhance the integration between healthcare and social work systems;
    • c) implementation of new models of integrated care.
  • Resource, education and training development - regions are encouraged to:
    • a) identify needs and create plans for skills development;
    • b) optimise skills (related to integrated care) in management and leadership, integrated clinical services, management of caregivers and health professionals;
    • c) promote a culture of shared responsibility and teamwork;
    • d) provide training, information and technology transfer for patients / users;
    • e) improve the health literacy of formal and informal caregivers.
  • Risk stratification - optimised and integrated implementation in care provision:
    • a) identify the needs of patients / users with regard to integrated care;
    • b) support partners in the implementation of risk stratification methodologies.
  • Implementation of care programs:
    • a) create synergies between existing and new financed activities (European Union, regional and local) in the development of instruments for implementing integrated intervention programs for chronic diseases;
    • b) develop the basis for provision of evidence-based care, creating guides and accelerating processes that lead to its implementation in the regions and institutions providing care.
  • Involvement of patients / users through health literacy and the promotion of healthy habits:
    • a) support patients / users in active participation and the pursuit of more efficient and integrated programs focused on the care of chronic diseases.
  • Electronic care register, information and communication technologies (ICT), teleservices:
    • a) highlight the potential of ICT and teleservices for efficiency in delivering more efficient and less costly integrated care;
    • b) improve the efficiency of ICT technologies used in social work and health, as well as for data sharing and identifying solutions that lead to improved interoperability between systems for recording and sharing data.
  • Economic management, funding, value creation and acquisition of goods and services:
    • a) align economic management and available funding to facilitate the shift to providing integrated care;
    • b) identify strategies for procurement of goods and services in order to support the adoption of integrated care for more regions.
  • Communication and dissemination:
    • a) integrated care at European level; effective involvement of partners from all Member States;
    • b) dissemination activities through the regions and organisations providing care in order to encourage the recruitment and retention of members in the partnership, and encourage European regions and organisations to scale and adopt care programs for chronic illnesses and integrated care programs.