Implementation pilots

Workpackage Implemention pilots

This Work Package is led by VIDAVO.

This work package focuses on the Implementation of the innovative UHC2.0 providing integrated care in 5 EU cities: Rijeka (Croatia), Rotterdam (the Netherlands), Valencia (Spain), Pallini (Greece) and Manchester (UK). For each site, based on the implementation plan, a plan of execution has been established which will include inclusion/exclusion criteria (together with WP7), and ready-to-use guidelines for ensuring the established standards for ethics and privacy, and monitoring of adverse effects during implementation (together with WP1).

First, at each site, the involved professionals and personnel has been trained to use the supporting IT modules, and apply the protocols for: (a) screening of frailty, (b) establishing shared agreed-upon integrated care pathways using formal and informal health and social care services of the UHC2.0 and related organisations, (c) integrated module for management of polypharmacy and adherence, and (d) multifactorial programme for fall prevention.

Then, at each pilot site, from month 12 onwards, during 6 months, 417 citizens/patients who are 75 years and older (many of them with multimorbidity, frailty or disability) in the community have been informed and invited to join the project and provide informed consent; also carers/family have been informed. So far, 2250 persons are included in the pilot sites, either in the intervention or in the control group. They joined the project during 14 months for integrated care interventions and follow-up for evaluation (WP7).

Recent outcomes

Among participants, the UHC2.0 team started with screening for frailty during a home visit by a nurse/assistant; this included a check on available (non-prescription) medication, drug use practices, and a home safety assessment. At the UHC2.0, the patient, carers/family, physician, and nurse/assistant, discussed the results, preferences and options; they took a shared decision regarding the personalised integrated care. This included management of polypharamacy (and adherence) and fall prevention.