Regional deployment of ICT-supported integrated care in FVG Region, with the involvement of different health and social care professionals and informal carers
Despite the good level of health and social care integration achieved in the FVG Region, there are rising needs in terms of ageing population, burden of non-communicable and chronic diseases, need of better involvement of informal care givers. SmartCare in FVG has deployed telemedicine and telecare services for people in chronic conditions, improving home-care services, providing ICT-supported integration of health and social care, and promoting active involvement of care recipients, family members and third sector.
The whole regional health system has been involved (17 health districts) and an integrated ICT solution has been developed to collect and share clinical and social data.
The ICT system included the following items: HEALTH PLATFORM as an online interface between medical devices and central storage unit database which collects data through home-based HUB data collector; technology devices at patients’ home for clinical and environmental monitoring that communicate data to the HUB (each device has its own memory and stores data until they are transmitted to and recorded by the HUB that works in the same way towards the central storage); a call centre and help desk.
The main stakeholders and beneficiaries of the practice: around 100 health and social care professionals, 170 informal care givers and 200 patients were recruited in two pathways (ICP-Discharge and ICP-LT Care) in Primary Health Care environment, mainly for chronic diseases.

Resources needed

The depolyment was financed with around 1,5 mln Euro. The whole ICT services was externalised and was payed through a services based system. The project was co-financed at 50% by the European Commission and at 50% by staff costs of ASUITs. The cost of the service was 4 euro per day/per patient.

Evidence of success

Randomized trial was carried out and evaluation gave evidence of savings in hospital admissions and duration of hospitalization, more statistically significant on post-discharge pathway than on long term.
Qualitative evaluation (QoL, PAM and other validated methods) demonstrated a very good acceptance of adopted ICT solutions from older people. SmartCare is now planned to be developed as a permanent service in FVG Region with a vision to pass from experimental to general care model.

Difficulties encountered

Difficulties encountered:
- Involvement of social care givers
- Involvement of general practitioners
- policy changes in the regional health system
- resistance to change
Lessons learned: need of political and top manager commitment; change management needed; positive attitude of end users

Potential for learning or transfer

SmartCare has proven potential for learning and transferability providing evidence of involvement of several stakeholders, active participation of end users and ICT solutions as support of existing care pathways and practices.
SmartCare has published also Guidelines for deployment of ICT-supported integrated care where tips and recommendations are given.
The project addressed common challenges and focused on treatment at home for patients with chronic disease, through a care model and ICT solutions that are widely transferable.
ASUITs decided to keep the service operational through its own resources. Through an Interreg it was decided to develop the service and the monitoring system with mobile kits, that include multi-patient monitoring devices to permit the application of the ICT solutions in different care settings (nursing homes and residential care organizations, prisons, etc) in order to explore new models of organisations of health and social care and continuity of care.

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Main institution
Health Authority of Trieste
Friuli-Venezia Giulia,
Start Date
March 2013
End Date
October 2016


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