Table Of Content. Coordinator, Leader contact and partners... 24

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1 Table Of Content Frailty management Optimisation through EIP AHA Commitments and Utilisation of Stakeholders input... 3 Summary... 4 Work Package Coordination of the project Dissemination of the Project Evaluation of the project Synthesis of learning and realities of practice Analyses and guidelines development Creation of Network and Platform for knowledge exchange Test of guidelines in a set of commitments Coordinator, Leader contact and partners ROESSINGH RESEARCH AND DEVELOPMENT BV ROESSINGH RESEARCH AND DEVELOPMENT BV ROESSINGH RESEARCH AND DEVELOPMENT BV UNIWERSYTET MEDYCZNY IM PIASTOW SLASKICH WE WROCLAWIU UNIWERSYTET MEDYCZNY IM PIASTOW SLASKICH WE WROCLAWIU UNIWERSYTET MEDYCZNY IM PIASTOW SLASKICH WE WROCLAWIU UNIWERSYTET MEDYCZNY IM PIASTOW SLASKICH WE WROCLAWIU ASTON UNIVERSITY ASTON UNIVERSITY ASTON UNIVERSITY ASTON UNIVERSITY ASTON UNIVERSITY ASTON UNIVERSITY ASTON UNIVERSITY FONDAZIONE IRCCS CA' GRANDA - OSPEDALE MAGGIORE POLICLINICO FONDAZIONE IRCCS CA' GRANDA - OSPEDALE MAGGIORE POLICLINICO FONDAZIONE IRCCS CA' GRANDA - OSPEDALE MAGGIORE POLICLINICO ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ISTITUTO DI RICERCHE FARMACOLOGICHE MARIO NEGRI ESCOLA SUPERIOR DE ENFERMAGEM DE COIMBRA ESCOLA SUPERIOR DE ENFERMAGEM DE COIMBRA ESCOLA SUPERIOR DE ENFERMAGEM DE COIMBRA ESCOLA SUPERIOR DE ENFERMAGEM DE COIMBRA UNIVERSIDADE DE AVEIRO UNIVERSIDADE DE AVEIRO UNIVERSIDADE DE AVEIRO EVERIS SPAIN SL Page 1/36

2 EVERIS SPAIN SL EVERIS SPAIN SL ESTUDIOS DE SOFTWARE AVANZADO Y MANTENIMIENTO DE TECNOLOGIA SOCIEDAD LIMITADA ESTUDIOS DE SOFTWARE AVANZADO Y MANTENIMIENTO DE TECNOLOGIA SOCIEDAD LIMITADA LANCASTER UNIVERSITY LANCASTER UNIVERSITY LANCASTER UNIVERSITY Outputs MD.4 Layman version of the final report Methodology Plan for Guidelines in a set of commitments Outcomes of the Test of Guidelines Report Plan for Risk Management Dissemination plan Dissemination report Plan and methodology design for the process evaluation Interim Evaluation report Final Evaluation report Report on synthesis of learning and realities of practice Analysis Plan Report on Comparative Analysis and Guidelines for decision making Report on the PKE functionalities MD.1 Interim report(s) MD.2 Final report MD.5. FOCUS Website MD.3 Leaflet Page 2/36

3 Frailty management Optimisation through EIP AHA Commitments and Utilisation of Stakeholders input JA GPSD [705038] START DATE: 01/05/2015 END DATE: 30/04/2018 DURATION: 36 month(s) CURRENT STATUS: Finalised PROGRAMME TITLE: 3rd Health Programme ( ) PROGRAMME PRIORITY: - CALL: Call for Proposals for Projects 2014 TOPIC: Adherence, frailty, integrated care and multi-chronic conditions EC CONTRIBUTION: EUR KEYWORDS: Clinical Test, Eipaha, Frailty, Guidelines, Optimization PORTFOLIO: Ageing Page 3/36

4 SUMMARY Project abstract Our purpose is to critically reduce the burden of frailty in Europe by assisting those partners within the European Innovation Partnership for Active Healthy Ageing (EIPAHA) with commitments focusing on early diagnosis/screening and/or management of frailty to achieve scalability. We have selected EIPAHA because it constitutes a critical instrument for the EU and because it composes the widest representation of initiatives about frailty in Europe. Our project offers both a service and a network. The service consists of evidence-based guidelines to critically help the selected group of partners to satisfactorily achieve their goals. The network intends to prolong the service in the long term. To achieve that purpose (WP4) we will define the roadmap, in that we will i) describe the state of art (review of the scientific literature), ii) get a picture of the status of the affected commitments within EIPAHA (barriers, enablers, etc.), and iii) obtain information of the needs of stakeholders. With this realworld landscape in hand, WP5 will define indicators and use a scientifically sound method, comparative effectiveness research, to draw conclusions regarding the most adequate and customized approach to assist commitments in achieving success. Inequalities, cultural conditions or cross-border issues will be considered as representative of the diversity in Europe. Guidelines and toolkits will be issued with the perspective of sustainability. WP6 will constitute the Platform for Knowledge Exchange (PKE), which will both facilitate and perpetuate exchange between partners and stakeholders to achieve synergies and guide progression. PKE will act as a repository and as an instrument for dissemination too. WP7 will be a practical test to verify the usability and performance of guidelines in real EIPAHA commitments. Relevance derives from the wide prevalence of frailty in Europe, consistently the focus throughout the work programme. Summary of context, overal objectives,strategic, relevance and contribution of the action ## **WHAT DID WE DO?** ### *The background* Ageing is a global phenomenon. The 2013 update of the World Health Organisation (WHO) has established life expectancy at 80 years for women and 73 years for men in the European Union (EU) (1). As a consequence, a total of 85 million European people are aged over 65 years, and it is thought that the number will double by Ageing increases the risk for disease, dependency and poor quality of life. The Page 4/36

5 European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) represents a pivotal reaction of the European Commission (EC) to that challenge. The European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) was created in 2012 (2) as a pilot initiative aiming at the promotion of healthy ageing through interdisciplinary and cross-sector approaches, and specifically aiming to reduce the gap between healthy life expectancy and actual life expectancy by 2 years. The health programme of the EC has boosted prevention as a key strategy to manage the challenges of ageing. This is the context in which the FOCUS (Frailty management Optimisation through EIPAHA Commitments and Utilisation of Stakeholders input) project was born. FOCUS is a project financed by the Health Programme of the European Commission. It integrates 11 different partners (University of Valencia, EVERIS Spain SL, and ESAM SL, all the three in Spain; Roessingh Research and Development BV in the Netherlands; University of Wroclaw, in Poland; Aston University and Lancaster University in the United Kingdom; Fondazione IRCCS Ca Granda and Istituto di Ricerche Farmacologiche Mario Negri, both in Italy; Escola Superior de Enfermagem, University of Coimbra, and University of Aveiro, both in Portugal). Our research activities in FOCUS were strongly related with prevention of dependency, decline and poor quality of life in later life as we concentrated our attention on frailty, a crucial concept in that regard. Frailty is a syndrome that relates to individual vulnerability for developing adverse outcomes when exposed to a stressor (3,4). Therefore, the attention to frailty aims at identifying the most vulnerable citizens. This group of the population is expected to consist of individuals who will be most likely to experience ominous outcomes, including disease, dependency, hospitalisation, necessity for nursing home admittance or death. Given evidence on the malleability of frailty, paired with the limited intervention at present, it is clear that by concentrating active measures in frail individuals to improve the condition, societal gains in health and social care burden will be maximal. ### *FOCUS as a decisive step* We conceived FOCUS to reduce the burden of frailty in Europe, but with a series of particularities. One was our special interest on EIPonAHA. Given that EIPonAHA includes a varied profile of stakeholders, another important feature of FOCUS was the consideration of their active participation. Therefore, the strategy to integrate those considerations into an effective reduction of frailty in FOCUS included: - The synthesis and appraisal of the most consistent scientific evidence. - The investigation of the views of different types of stakeholders, including frail and robust older adults in community and healthcare situations, carers, health and social care professionals, and policymakers. - The categorisation and appraisal of Good Practices in the EIPonAHA portfolio guidelines and recommendations of conditions for success. Page 5/36

6 - The test of those guidelines in pilot clinical and community studies run in 5 different EIPonAHA settings across Europe. Specifically, 5 different countries, Spain, Poland, Italy, Portugal and the UK housed pilots that gave corresponding reports about how those guidelines performed in real world practice. - But the roadmap of FOCUS also included more innovative measures. Specifically, FOCUS worked on disclosing how modern information and communication technology (ICT) Methods and means # **Methods and means: Work performed during the reporting period** ## The point now is **HOW DID WE DO THAT?** Work to comprehensively respond to our aims and the much needed advance in the area of frailty and frailty interventions included an ambitious set of reviews of the existing scientific evidence, an endeavour which was well supported by our analysis of the reality of actual interventions in Europe via the EIPonAHA Good Practice portfolio. Crucially, the outcomes of these activities were synthesised with the involvement and input of a wide array of stakeholders, citizens, carers, policy makers, experts, academia, and companies, ensuring the involvement of people affected by frailty or with some responsibility for their care. So, the first half of the project, between May 2015 and November 2016, concentrated on an extensive and meticulous review of the literature and of the EIPonAHA Good Practices. This enabled us to gain insight into both scientific reports of screening and interventions for frailty and also the implementation of these in the real world. This was completed with a direct survey to individuals responsible for the interventions featured in EIPonAHA portfolio to investigate barriers, facilitators and conditions for success, thus including direct contact with stakeholders. To further explore the views of stakeholders, another review synthesised qualitative reports that had focused on the lived experience of frailty and frailty interventions from the points of view of frail older people, their carers, and health and social care professionals. We then used our findings to prepare further investigations of perceptions of frailty, frailty management and intervention with our own focus groups, with specific topic guides customised to each particular profile. These focus groups were conducted in three countries, UK, Poland and Italy, with the purpose of learning from the main actors: frail and robust older adults, the informal (family) carers, and health and social services staff. Following the analysis of all the above work, we put together a summary Page 6/36

7 particularly emphasising the main themes of concern that came out of the synthesis of qualitative reports and our own focus groups, but including the information on the success of specific types of frailty interventions for people even of very old age. We wanted to disseminate this to European policy makers and to have their response. So, we interviewed representatives of different levels, from the European Commission to the regional level, but all with responsibility for health funding and organisational decisions and policy on frailty. We also interviewed specialists, who were selected from the direct and indirect contacts of each of the partners in FOCUS. Following our analysis of this qualitative data, we have disseminated the outcomes directly and also much more widely in a high profile published output (5). In the course of all that intensive work we were able to select and validate a long list of valuable **indicators,** which were then used in the production of the **guidelines**. The guidelines were prepared with the use of a validated approach that included both the GRADE and the PICO methodologies. In addition to the guidelines on the types of interventions that work, we also produced a set of **recommendations for the success** of those interventions, for example, to improve adherence on the part of patients or staff, or to ensure an intervention could work in a particular organisational context. #### *The test of the guidelines: preparation and execution* A multi-centric feasibility study (described as a series of pilot studies) was prepared to test the guidelines. This approach is highly relevant to our cross- Europe scaling up aims, in that the performance of guidelines and recommendations was tested in different environments, with different protocols, and in five different Member States. This included meticulous preparation of the t Work performed during the reportingperiod ### **WHAT WERE THE RESULTS?** The answer to this question may be stratified in sections, according to the result profiles. #### *Evidence to prepare the guidelines.* Page 7/36

8 The updated scientific evidence received the input from the real world and produced results in the form of a series of publications. The principal papers were as follows: we completed a systematic review on the effectiveness of interventions to prevent pre-frailty and frailty progression in older adults (6). This article clarifies what types of interventions work to prevent or reduce frailty in the real world. The issue is crucial, of course, and it is a mandatory step in order to have evidence to allow for the most appropriate set of guidelines. Another important paper has been a realistic review, which has been a critical step because this publication updates what works for whom and in which circumstances (7). The paper was another important source of information in the preparation of the guidelines. It brought together work from the systematic review (6), the umbrella review of screening tools for frailty (8), the survey of Good Practices (9), the metasynthesis of qualitative studies (10) and the focus group investigations (11). #### *The guidelines* This was a main outcome of FOCUS, a service that the consortium offered to society. The rich background of information made the preparation of guidelines one unique initiative, as both the stakeholders views and the comprehensive, critically reviewed, scientific evidence were incorporated in the analysis. There was a meticulous process of identification, selection and validation of indicators, organised in a multidimensional framework, which were taken for characterisation and comparison. The validation involved a panel of 83 European experts from the health and social care sectors identified and invited by FOCUS partners. The entire process followed a methodology developed by University of Aveiro for the project. University of Aveiro led the process, working with Mario Negri and Policlinico Milano and contribution from other partners. #### *The test of the guidelines* After the completion of the 5 trials, results were subjected to a meticulous analysis to draw conclusions. The big question was about the performance of the guidelines. FOCUS investigators provided important conclusions about feasibility (with 4 sub-domains, practicality, usability, closeness and responsiveness) and satisfaction. All of them were ranked as high or very high in terms of appreciation of partners and end-users. Some quotes from participants: From the pilot in Valencia, Spain: * I repeat it went very well. Suggestions I cannot give, I thought everything was great. Just tell you that it has been a fantastic experience. Thank you very Page 8/36

9 much.* From the pilot in Birmingham, UK: * It prompted me to try and get fitter and get involved in more activities ( ) talking about your diet and activities, it prompted me to do more than I was doing.* #### *One more step: medical economics analysis* This has been a very ambitious attempt, in which both the technical support of RRD and EVERIS has boosted the tasks developed by ESAM. The challenge has been to produce evidence concerning cost-effectiveness in relation to frailty. This is an unexplored area, which is currently full of complexities to overcome. Our analyses integrated a complex list of variables, including consumption of resources, health care utilisation and cost analyses, budget impact, and incremental cost-effectiveness ratio, which were matched to each frailty indicator. We detected some isolated findings, such as reduction in the number of visits to the GPs in groups allocated to the guidelines intervention. However, overall comparisons on economic effectiveness were not possible because of the heterogeneity of environments. #### *The ICT support* Two partners, Everis and RRD, worked together to produce the PKE and the PSU. The PKE is a m The main output achieved so far and their potential impact and use by target group (including benefits) # The main outputs achieved so far and their potential impact and use by the target group (including benefits) Three main questions are relevant now: ## **HOW DID WE HELP EU CITIZENS?** Page 9/36

10 The versatility of FOCUS guidelines, which proved to be beneficial in all the different circumstances, may become a tool for health professionals, social workers, and the end-user. The conclusions are important in terms of usability of the guidelines, demonstrating that they maintain their operability in the many varied settings of the real world. Additionally, our modelling of the impacts of change in frailty using a continuous variable as opposed to a categorical variable (using full range frailty score rather than categories of frail, pre-frail or not frail) enabled us to demonstrate that any reduction in frailty, even if tiny, has impacts on health and social care gains and on quality of life. The PKE and the PSU may be of help as well. The PKE constitutes a resource capable of offering updated information and, at the same time, direct implication in the area of frailty. The PSU offers the ReQuest tool, a system that has already been tested in PERSSILAA, another European project. ReQuest is a tool with potential for scaling up. ## **WHAT DOES THIS ACTUALLY MEAN FOR EU CITIZENS?** European citizens are gaining life expectancy, even taking into account our varying geographies, cultures and economic variability. This affects all of us, no matter how old we are at present. The topic (frailty), and the FOCUS outcomes are important for us all. Specific important conclusions are: 1. Our updates from the scientific literature (systematic review, realistic review, umbrella review, etc.) unanimously confirm that the frailty status may be reversed to a less vulnerable profile, even to a robust status if frailty was not too advanced. This is a crucial message for you, your doctor, and your full family and community context. So, something can be done! Have a look at our video on. This is now available in seven European languages (12). 2. Again as a consequence of the evidence updating, and in consistence with our guidelines recommendations, it is clear that lifestyle plays an important role in maintaining a robust state. Physical activity and good nutrition are important tools in that regard, but so too are social and intellectual engagement and psychological robustness. Consequently, a great message is to keep fit, eat healthily and keep your brain active! Doing all this together with your friends and family is even better! 3. Because integrating these habits in your life is not always easy, you may check the guidelines and recommendations to get some ideas as to how to help the process of getting good habits. Appropriate strategies to integrate into good practices, or facilitators to make healthy lifestyles a standard reality, are found in the list of recommendations that go with the FOCUS guidelines, see Table 3 in the Realist Review [7]. 4. The results of the feasibility trials (pilot studies) in FOCUS will further reinforce the conclusion about what you can use in your own contexts and how acceptable participants found the methods to be, in case you have any doubts. 5. Finally, you will have the technological platform in the two variants, the PKE Page 10/36

11 and the PSU to support your endeavours to address frailty in your own life and in your professional contexts. ## **DO I HAVE ANY BENEFIT?** The answer is yes. You will be assured about the prospects for a healthier horizon if you make efforts to keep the guidelines recommendations. Maintaining attention on the FOCUS guidelines not only informs you what activities can improve robustness, but also suggests strategies that support your adherence to healthy lifestyle choices. We are also hoping that professionals across Europe will be using these guidelines to inform their design of good interventions for their local populations. The g Achieved outcomes compared to the expected outcomes One of the main objectives of the project, the consolidation of evidence and corresponding publications, has been achieved, although our final papers are suffering the slow progression of acceptance and publication as is the rule for high quality scientific journal. As an example, the guidelines are a reality, available as a deliverable, but not yet as a publication, although the recommendations for success of the guidelines in a range of contexts is available in the Realist review [7]. However, the list of published papers already available is far in excess of our original expectations, which is testament to the rich set of findings and the industrious involvement of all partners. Another area worth commenting is the analysis of stakeholders and of the commitments of EIPonAHA. It has been the FOCUS experience that the list of groups working on frailty in EIPonAHA was relatively limited (little more than 100 projects listed), and that some of them did not reply to the request to fill the questionnaires. This is a lesson in itself, which warns about the difference between the formal lists of partners and the real world. Even so, the list of experts who did respond attained a minimum threshold, which allowed for a reliable selection of indicators and useful knowledge sharing about what facilitated or provided barriers to successful operationalisation of frailty interventions. The technological platform is a product that has been forced to be often re-adapted. While the technical design and fabrication were satisfactory at all stages, the strong competition from alternatives derived from other Page 11/36

12 projects or by the own EC (The Health Policy Platform, for example) created difficulties for being sufficiently competitive. Finally, the pilots were completed as they had been designed, with satisfactory outcomes. We found some difficulties in the health economics evaluation. Among the limiting factors was the fact that frailty is a variable in which changes are very difficult to translate into economical impact. Dissemination and evaluation activitiescarried out so far and their major results Dissemination has been huge, and has attained several forms: We developed a website, which has been located within the PKE and PSU ([focus-aha.eu]( The FOCUS dissemination plan has been enriched with a new set of dissemination resources, the FOCUS Project Dissemination Toolkit, which includes the dissemination tools, and the Guide to the FOCUS Project Dissemination Toolkit tools. One main asset of the project has been the scientific dissemination. As already mentioned, there are papers in scientific journals (10 in total and still some others in the pipeline, either in publication process (3) or in preparation (3)). There is also dissemination in academic conferences, workshops with healthcare practitioners and senior decision makers, and events to disseminate outcomes with older citizens who have taken part in the pilots, and many other examples. Of interest, there is a series of videos in all the languages of the partners in FOCUS. They have been used as an easy system to transmit basic messages in an accessible manner. They have been uploaded to YouTube, giving a huge potential to be visible in many different environments worldwide. The FOCUS Newsletters have become a regular document highlighting important activities by partners or related with FOCUS in one way or another. Also important, 4 workshops have completed the project meetings at each of the locations and have gathered a specialised set of participants from the whole array of stakeholders, involving their viewpoints at the various stages of the work, ensuring that the needs of potential end-users have been incorporated at every stage. Page 12/36

13 Other initiatives of interest include a long list of press briefings, often through the institutional press services of partners institutions, or through more general mass media dissemination channels, including radio or online. Also important to mention is a network of stakeholders who have registered to receive updates and access information regarding the outcomes, another important dissemination achievement of FOCUS. Finally, a list of initiatives, as detailed in the FOCUS Dissemination Plan, has open channels and relationships that might be used in future actions. In this way, the potential of FOCUS dissemination may be maintained in the long run. Page 13/36

14 Work package Work Package 1: Coordination of the project Start month: 1 End month: 36 Work Package Leader: UVEG Task 1.1 Coordination with the European Union for administrative, financial and other issues (M1-M36). Assuring the regular contact with the Project Officer Distribution of the contribution of the European Union between partners. Management of the outputs of the project that should be transmitted to the European Union, like collection and submission of: o Periodic reports. o Financial issues o Deliverables o Other matters Task 1.2. Coordination and management of the project (M1-M36). This task refers to the group of activities that relate with the effective implementation of the project. Consequently, this will involve: Constitution of a Core Board, integrated by the Coordinator and the Work Package Leaders. Definition of a Project Coordination and Management Plan by the Core Board. Establishment of the required conditions for a fluid coordination between partners. This will include: o Kick-off meeting. o Project progress annual meetings with all partners. Tight monitoring of the progression of the project, which will include o The design of effective control measures, which will be coordinated with WMU. Survey activities will be met by WMU, while UVEG will keep more executive functions. o The use of required interventions to keep the implementation on schedule, o The preparation of contingency and corrective actions in case of deviations (in consistence with the Project Coordination and Management Plan), Preparation of the contractual periodic management reports on time. Task 1.3. Promotion of the excellence in the implementation of the project (M1-M36). The purpose of this task, which will be also implemented in close collaboration with WMU, is the establishment of every action to warrant that the development of the project is materialized under the premises of the required quality and excellence. For that: An agreement about quality conditions will be adopted by partners in the consortium. Document reflecting the main conclusions of this agreement will be produced. As mentioned below (WP3), evaluation reports about the quality of WPs implementation will be generated by WMU. This information will be taken in the Page 14/36

15 present WP to act accordingly. Task 1.4. Plan for Risk Management (M3-M9). The Core Board will perform a detailed scan of the susceptible areas of the project subjected to risk, including the work packages, deliverables, milestones as well as the progressive performance of the groups themselves. This will include: Definition of the main possible threats. Main features to be subjected to analysis. Establishment of a periodicity for such scanning (6 months), which will be analyzed in each annual meeting of the consortium. Contingency plans for the described threats. Work Package 2: Dissemination of the Project Start month: 1 End month: 36 Work Package Leader: UAVR Task 2.1. Development of project website and intranet (EVR) (M 3) This task will focus on the development of an external project website hosted at The website will include a description of the project, the consortium and the pilot sites. It will also contain a list of public deliverables from the project and will provide access to all relevant public publications. The FOCUS website will be the access gate to the FOCUS PKE, as detailed in WP6. A mirror site will be included in all partners websites. This will allow for project internal communication and collaboration. A partner-restricted information repository will be hosted at the PKE as well. Task 2.2. Development, implementation, monitoring and assessment of FOCUS dissemination strategy and plan (UAVR with support of UVEG, RRD, WMU, ARCHA, POLIMI, IRCCS-MN, ESEnfC, EVR, ESAM)(M6-M36). This task will develop and implement the dissemination strategy and plan for the project results using a variety of communication channels. This task will also be responsible for monitoring and assessment of all dissemination activities and respective impact, providing critical information to WP3 (Evaluation). Together with UAVR, the other above-mentioned partners will assist in this task. Dissemination will target all the identified groups of stakeholders. Work in this task will include the following activities: elaboration of the dissemination strategy and the dissemination plan organisation and implementation of dissemination activities for the all partners and Consortium monitoring and assessment of dissemination activities and respective impact participation of the Consortium members in various events related to the theme of the project Dissemination methodologies will include conferences, publications, keynote speeches, events, digital resources, educational resources. Dissemination will start at project kick-off with the publication of news on the FOCUS and the partners websites and a dedicated press release. The consortium will do its best to reach Page 15/36

16 mass media channels on this phase of the project. During the course of the project, regular communications efforts will be made towards all industry related sectors, via newsletters or presence at industry seminars; the support of the collaborating stakeholders, most of them patients associations or institution with a wide representation throughout Europe, like the Institute for Longevity Centre for example, will be considered. In addition, the project will publish articles or white papers and make presentations at industry conferences. Peer-reviewed articles will be deposited within 6 months of their publication in open access databases. Dissemination will also address policy makers by two ways, the contacts during the development of focus groups in Work package 4, and by publishing and delivering the results of FOCUS activities. Task 2.3. Scientific dissemination (UAVR with support of UVEG, RRD, WMU, ARCHA, POLIMI, IRCCS-MN and ESEnfC) (M4-M36) This task focuses on identifying and organising thematic scientific dissemination activities based on the project dissemination plan such as producing quality scientific articles and posters. The strategy is to publish the project findings in open access journals and databases. Task 2.4. Market dissemination and ecosystem development (UAVR)(M4-M36) In this task, we will actively promote FOCUS products and achievements, methodologies and knowledge to the market, and will push the initiation of an ecosystem around the project ideas. Various market dissemination activities will be organised such as industry-oriented seminars. The main goal is to foster the sustained growth of the FOCUS network, reaching more professionals, companies, associations and citizens. Work Package 3: Evaluation of the project Start month: 1 End month: 36 Work Package Leader: UM WROCLAW AM WROCLAW Figure 7 Description of evaluation (see Annex A in Part B of Annex 1) Figure 8 Evaluation strategy (see Annex A in Part B of Annex 1) Levels of evaluation: each WP (detailed level) and effects of cooperation between all WPs (general level) Process evaluation: participation of the collaborating partners in implementation of the project (research methods: personal interviews, questionnaires (online survey). Outcomes evaluation: Indicators specified according to planned deliverables of the particular WP. An internal and external evaluation will be conducted to inform the project partners about the status of the project. The internal evaluation is based on: 4 structured questionnaires about the expectations and the satisfaction of the project partners. The first questionnaire will be placed at the beginning of the project and will start after the kick off meeting. The next questionnaires are planned at the end of the first, second and third year. Additionally the WP leaders will be asked to write every three month short reports Page 16/36

17 about the activities and the status concerning their WPs. These short reports will allow monitoring if activity and output indicators are met, if the utilization of financial and personal resources is in line with the course of the project, if unexpected challenges and conflicts emerge and if respective action has to be taken. Questionnaires will be also distributed at the end of each general meeting (opinion about the value of the outcomes, the organizational efficiency, the internal and external communications difficulties) as well as the questionnaires: about the interim and the final report (quality, usefulness) and partners efforts. As a result of cooperation with the WP1 all information from questionnaires and reports will be shared and discussed with leaders of all WPs. The external evaluation (feedback from independent experts about the project s outcomes) is planned to be conducted by specialists for cross border activities and legal issues. The external evaluation will not only look at activity and outcome indicators but also focus on the quality of the project output. The collaborating stakeholders will be contacted. The findings of the internal and external evaluation will be documented in the interim report of evaluation and the final report of evaluation which will be integrated within the interim and final reports prepared by the WP1. Task 3.1. Close cooperation with the WP 1 - Management of the Project (M1-36) Task 3.2. Evaluation of the achievement of each objective/deliverable of the project (M 1-36) Task 3.3. Evaluation of the correctness of the WPs deliverables through internal and external evaluation (see the indicators of evaluation) (M 1-36) Task 3.4. Evaluation of the satisfaction of the participants (general organization including general meetings) (M 1-36) Task 3.5. Evaluation of the communication between participants through the internal evaluation detailed above (M 1-36) Task 3.6. Communication with each WP leader to detect as soon as possible deviations from initial plans and to inform the project management team (M 1-36) The indicators of evaluation: WP1: Evaluation of the project progress and management Benchmark 1: the list of Golden Rules for Excellence - a set of minimal requirements to be kept in order to warrant excellence, this document will describe the limits of deviation for the main magnitudes - this includes the absolute refusal to more than agreed delays on deliverables, or to excess beyond the established limits for expenses in WPs, or to poor rating of deliverables when submitted to assessment. Benchmark 2: publication of the interim and final report. Level of project management - results of the questionnaires Benchmark: 70% of the respondents who found the communication (internal and external outside of the consortium) good or very good. WP2: Level of dissemination (information about the project and the outcom Page 17/36

18 Work Package 4: Synthesis of learning and realities of practice Start month: 1 End month: 20 Work Package Leader: ASTON U The WP consists of four tasks: 1. Synthesis of existing published evidence; 2. Putting stakeholders perspectives at the centre; 3. Exploring the real world: learning from current practice; 4. A structured summary of the realities. ARCHA will coordinate and supervise the entire WP4, and will directly lead Task 4.3, with the contribution of all the other partners, and specifically contribute to all other tasks. MN will lead Task 4.2. POLIMI will lead Task 4.4 and contribute to other tasks. ESENFC:CU will lead Task 4.1 and contribute to Task 4.2 (i). WMU will contribute to all 4 tasks. UVEG and RRD will contribute to Task 4.1. All applicants will support the survey of the EIP AHA Good Practices, using their different national contexts and expertise to support the extraction of data. These tasks will be accomplished using insights from international high quality published research and reviews, from a survey directed towards the EIP AHA Good practice projects and from practitioners, providers, carers and patients themselves using a range of methods. Outcomes of the components will accumulate to form specific deliverables of systematic review, input database for WP5, and a critical realist review putting together outcomes of sub-tasks within this workpackage. The inclusion of a range of healthcare settings and expertise across EU cultures will enable consideration of cross-border interoperability and diversity. Outcomes will specifically link to WP2 in terms of policy dissemination, to WP5 in terms of providing the more detailed data on the Good Practices for the comparative analyses, to WP6 in terms of the Platform for Knowledge Exchange (PKE) and elicitation of feedback from users, and WP7 in terms of contributing to the design of the assays in practice. Task 4.1. Synthesis of existing published evidence. Months M1-M12 (ESENFC:CU) (i) Frailty assessments could prove to be valuable tools to caregivers of patients and health care providers in terms of planning needs and care, and to identify atrisk individuals to whom interventions can be offered. The first component of this task will be a systematic overview of existing high quality reviews on screening for frailty, compiling evidence from multiple systematic reviews. The aim is to summarize reviews that assess (i) Utility of screening in terms of detecting or predicting risk and (ii) diagnostic accuracy of currently available and published tools that assess frailty in older adults in terms of outcome prognostics. The review questions are: What is the reliability and validity of existing screening tools that assess frailty in older patients? What is the comparative sensitivity and specificity of different frailty assessment tools in identifying patients at risk of a poor prognosis? How do the characteristics of different tools match the different samples within the frail/pre-frail populations? What is the best fit between available tools, purposes (e.g. to predict need for care, mortality or potential response to intervention) and contexts/populations to assess frailty in older age? Page 18/36

19 Can a set of standardised tools for frailty be applied across EU contexts? Reliability, content, criterion and construct validity, sensitivity, specificity, and, where available, positive predictive values, negative predictive values and likelihood ratios will be examined using methods described in the problem analysis section. Data will be extracted and synthesized in order to answer the review questions. (ii) The frailty syndrome is a pre-disability condition suitable for targeting by evidenced preventive interventions. A systematic review will be conducted to determine the effectiveness of interventions, treatments and rehabilitation within frail and at risk ( pre-frail ) patients, aimed at preventing progression from prefrailty to frailty and improving prognosis of patients already defined as frail. Given that some assessments for frailty use multi-morbidity as a c Work Package 5: Analyses and guidelines development Start month: 12 End month: 24 Work Package Leader: IRCCS CA' GRANDA The WP consists in four tasks: 5.1 Identification, selection and validation of indicators for characterization and comparison; 5.2 Comparative Analyses of EIP AHA commitments; 5.3 Modelling predicted needs and resource consumption; 5.4 Developing guidelines as a service for implementation and customized scalability. POLIMI will coordinate and supervise the entire WP5, and will directly lead task 5.4 and contribute to the other tasks. UAVR will lead task 5.1 and contribute to task 5.2. MN will lead task 5.2 and contribute to task 5.1. ARCHA will lead task 3 and contribute to task 2. RRD will contribute to task 5.1, 5.2 and 5.4, and WMU to task All the applicants will be involved in the collection of relevant data and databases, requiring also the connection with all EIP AHA partners. This WP will be supported by the functionalities developed in WP6. Task 5.1. Identification, selection and validation of indicators for characterization and comparison (M12-M16) (UAVR) The literature review, the EIP AHA profiles survey and the qualitative study performed in WP4 will represent the main source of identification of relevant indicators. European Commission documents and existing standards established by local or national authorities to guide the implementation of interventions on frailty and related fields will be taken into account as additional sources of indicators. All the identified indicators will be organized according to 3 criteria: 1. The object of measure: Structure, Process or Outcome 2. The area of relevance: Health or Social area 3. The area of application: Prevention or Management 1. Object of measure Concerning structure indicators, the type and the amount of the available health and social services and professionals, and of the economic resources (public and private) specifically involved in each EIP AHA commitment, will be considered. Concerning process indicators, we will investigate how the interventions work, the trajectories, the coordination and integration between the involved personnel, the existence of protocols, standards and regulatory plans for monitoring and evaluation. Page 19/36

20 Outcome indicators can include both general impact indicators (such as the number of subjects reached by the intervention, the degree of inclusiveness in terms of participants sociodemographics), and specific outcome indicators, e.g. mortality, hospitalizations, drug prescription, institutionalizations, falls, living or dying alone. 2. Area of relevance The identified indicators will measure structures, processes or outcomes in the health or social area. 3. Area of application Some indicators will be specific, some other will be common across the prevention and management areas, where the prevention area will encompass those actions aiming at preventing the switch from wellbeing to an unhealthy condition, the progression from pre-frailty to frailty, and might include preliminary strategies to screen the physical, cognitive, psychological and functional states related to the development of frailty. The management area will include any intervention aimed at improving the outcome of frail subjects or even at reversing a condition of frailty. A set of indicators will be selected from those previously identified, according to criteria of relevance in decision making processes in real world, responsiveness to stakeholders and EIP AHA members needs as elicited in WP4, and applicability and adaptability across different realities and sub-populations. Delphi-like methods and focus groups among experts and stakeholders, supported by ICT functionality, will be used for the selection, as well as for the detection of additional relevant objects and areas to cover with ad-hoc indicators, in order to achieve a consensus on a final set. Task 5.2. Comparative analyses of EIP AHA commitments (M14-M20) (MN) EIP AHA practices will be qualitatively and quantitatively characterized upon the indicators identified in task1. Although we cannot c Work Package 6: Creation of Network and Platform for knowledge exchange Start month: 4 End month: 35 Work Package Leader: EVERIS SPAIN SL Task 6.1. Constitution of the Network Committee and analysis of user requirements (M4-12) (UVEG) This task starts with the constitution of the Network Committee between partners within the consortium and stakeholders representatives. The Collaborative Stakeholders (see section 12, at the end of the document), will act as a first nucleus. Together with partners, a collegially taken decision will provide the selection between stakeholders participating in the Focus Groups in WP4. Then, the constituted Network Committee will define the regulations for their activities and the new incorporations. Starting from this shared vision, different scenarios will be developed for both knowledge exchange and for scaling up good practice, considering the definition of functional and non- functional requirements. Task 6.2. Technical requirements and Architecture of the Platform for Knowledge Page 20/36

21 exchange (PKE). (EVR) (M11-M16) Despite future improvements and refinement of the requirements after Task 6.1, preliminary needs have been identified common to a useful collaborative environment. These preliminary requirements of the PKE are: The inclusion of data referring to previous projects developed by the users of the platform A search engine that enables the user to search for different kind of information (publications, projects ) and also search for metadata. An interexchange of comments, questions and suggestions among the users and stakeholders (virtual communication platform including wiki, forum or Skype) A form editor and publisher that will enable the creation of questionnaires and Delphi analysis. Fitting databases either created during the progression of the EIPAHA survey, as detailed in previous WP, or already existing as a strong endowment in various groups. Exchange may be thus extended in a much wider sense. Dissemination of the best practice report/white book/toolkit delivered by the consortium. Be the basis for facilitating the access (bilateral/multilateral) at the levels of stakeholders-patients, partners-partners, and partners-patients. Help to sustain the achievements of the project and, although not being the philosophy of this Call, promote future projects and developments. This would require being updated and maintained, something that may translate into a business area. Task 6.2 will take care of designing the most efficient architecture for the PKE based on the previous requirements, the outcome from Task 6.1 and the envisaged scale of users utilising the platform. Task 6.3. Technical requirements and Architecture of the ICT platform for scaling up (RRD) (M11-M16) Using the results of T6.1 scenario based requirements engineering analysis will be applied to define functional and technical specifications of this part of the ICT platform. Besides the user-cantered perspective of PACT, the designer-centric components related to system use will be added using Function and events, Interactions and usability issues, Content and structure, Style and aesthetics (FICS) The FICS approach is more system descriptive and provides insights for technicians to consider the technical specifications. (additional) Functional and technical requirements are refined by iterative validation with the users. Some preliminary requirements are already defined and consist of: - The ICT platform is modular and flexible in such a way that new good practice modules can be implemented and selected - The ICT platform contains modules for remote screening of frailty - The ICT platform contains modules that enable remote treatment of frail older adults, with or without multi-morbidity. - The ICT platform is accessible for multiple stakeholders involved in the care around a patient Task 6.4 Development of the ICT infrastructure for Knowledge Exchange (EVR) (M16-M32) After obtaining the final version of requirements for the PKE, as a combination from Task 6.2 and Task 6.1, the final ICT infrastructure will be develope Page 21/36

22 Work Package 7: Test of guidelines in a set of commitments Start month: 24 End month: 35 Work Package Leader: UVEG This WP7 is connected with WP4, which will provide the data used to generate the indicators; with WP5, which will provide the guidelines to optimise the implementation of commitments; and with WP6, which will provide the platform for knowledge exchange, the technological instrument that will ensure an easy interplay between the relevant actors. This WP7 will be led by UVEG with the direct participation of ARCHA, WMU, POLIMI and ESEnfC in all tasks. ESAM will lead task 7.4 in order to assess the monetary impact of the changes implemented as a result of the application of guidelines. Task 7.1. Baseline assessment of the selected commitments and definition of methods and modalities of the optimisation strategy. (Months M24-M26). The commitments selected correspond to those run by UVEG, ARCHA, POLIMI, WMU and ESEnfC. The assessment has to be built over the conclusions gathered in WP4, which will have analysed these commitments in the context of the survey. To determine the optimisation strategy that will test the service, a series of preliminary actions will be required: Constitution of the Core Committee, integrated by the partners (the leaders of the participating commitments) and representatives of stakeholders (members of the constituted network in WP6). This Core Committee will direct the implementation of the whole WP. Assessment of the status of each commitment in terms of progression along the predefined schedule, committed deliverables and impact. As commented above, this activity will be developed upon the basis provided by the survey performed in WP4 and upon those from the developing outcomes of the comparative analyses. Further interim analyses of preliminary data possibly made available by the leaders over the project duration will be conducted. Definition of the indicators to be included in the evaluation. Impact indicators (i.e. indicators that will measure the changes produced in the commitments by the optimisation strategy) shall be chosen with the limited duration in mind. That is, some of the specific outcome indicators in WP5 may not lead to detectable changes in the short period (6 months), and so use here may not be feasible. Instead, changes in some of the structure and process indicators will be measurable. Feasibility indicators will measure other relevant aspects of the service such as practicality, usability, closeness and responsiveness to the reality as judged by the actors participating in the process (leaders of commitments, other care providers and patients). Finally, the overall satisfaction of the participants will be measured. Definition of the adjustments and amendments necessary to comply with the best practice according to the generated guidelines. Thorough registration of the barriers to the definition and adoption of the best Page 22/36