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

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 long-term 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 and Diabetes. 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