Table Of Content. Appropriate care paths for frail elderly patients: a comprehensive model... 2 Summary... 3 Work Package... 7

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1 Table Of Content Appropriate care paths for frail elderly patients: a comprehensive model... 2 Summary... 3 Work Package... 7 Coordination of the project... 7 Dissemination of the project... 7 Evaluation of the project... 7 Best practice analysis... 7 Model design and adaptation... 7 Data interoperability... 7 Hospital care module implementation... 7 Coordinated care management module implementation... 7 Prevention module implementation... 7 Impact and Sustainability Analysis... 7 Coordinator, Leader contact and partners UNIVERSITAT DE VALENCIA UNIVERSITAT DE VALENCIA UNIVERSITAT DE VALENCIA UNIVERSITAT DE VALENCIA ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM GRUPPO DI RICERCA GERIATRICA GRUPPO DI RICERCA GERIATRICA Outputs APPCARE Layman version Final report External evaluation final report Report on interoperability solution Hospital care model implementation Coordinated care model implementation plan Prevention model implementation plan Final impact assessment and sustainability Interim Progress Report and Financial Statement APPCARE model APPCARE leaflet APPCARE website EU synthesis report Page 1/20

2 Appropriate care paths for frail elderly patients: a comprehensive model JA GPSD [705038] START DATE: 01/07/2015 END DATE: 30/06/2019 DURATION: 36 month(s) CURRENT STATUS: Ongoing 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: Best Practice, Co-Morbidity, Coordinated Care, Data Interoperability, Frailty Risk Factors PORTFOLIO: Health systems expenditure, Health systems organisation, Healthcare, Supply of radio-isotopes for medical use Page 2/20

3 SUMMARY Project abstract Ageing problems are a common challenge for Europe and health systems: higher frail population in need of long term care, chronic conditions requiring complex response from a wide range of health professionals, often characterized by fragmented and not appropriated care. +65 patients access to ER more frequently; they stay longer to ER usually ending into ordinary admission, with an increasing risks of hospital-related adverse outcomes. APPCARE project aims at creating a new model for the management of frail elderly people including -standardized application of Comprehensive Geriatric Assessment (CGA) -homogeneous and coordinated care pathway, shared among all the involved care givers, traced by the geriatrician on the basis of CGA and performed through the establishment of a care management program particular hospital admission care path for +75 patients, with short intensive observation period -close link hospital-territorial care -frailty prevention program to demonstrate how an innovative and comprehensive management of complex and co-morbid clinical situations, may maintain patient s functional status in its clinical trajectory, optimizing health care systems. APPCARE will design the model on the basis of best practices already tested in the involved territories, to evaluate scalability of these existing strategies. Relevance to 3^ Health Progr.: APPCARE model is built up in order to achieve a complete and coordinated standard of care for frail patients, where all the involved caregivers agree and follow a homogeneous care path traced by geriatric specialist. This is perfectly in line with the addressed topic, reflecting the EIPAHA strategic plan. It answers the calls for better cooperation and communication between primary healthcare professionals and geriatric professionals to deal with problems of frailty and comorbidity reduction of unnecessary hospitalization and prevention of the related adverse outcomes early diagnosis and screening for frailty risk facto Summary of context, overal objectives,strategic, relevance and contribution of the action Ageing problems are a common challenge for Europe and health systems: higher frail population in need of long term care, chronic conditions requiring complex response from a wide range of health professionals, often characterized by fragmented and not appropriated care. +75 patients access to ER more frequently; they stay longer to ER usually Page 3/20

4 ending into ordinary admission, with an increasing risk of hospital-related adverse outcomes. APPCARE project aims at creating a new model for the management of frail elderly people including: - standardized application of Comprehensive Geriatric Assessment (CGA) - homogeneous and coordinated care pathway, shared among all the involved care givers, traced by the geriatrician on the basis of CGA and performed through the establishment of a care management program - particular hospital admission care path for +75 patients, with short intensive observation period - close link hospital-territorial care - frailty prevention program to demonstrate how an innovative and comprehensive management of complex and co-morbid clinical situations, may maintain patient s functional status in its clinical trajectory, optimizing health care systems. APPCARE will design the model on the basis of best practices already tested in the involved territories, to evaluate scalability of these existing strategies. Methods and means The project will deploy accordingly to the following steps: Analysis of pilot sites contexts and review of best practices in the field of integrated management of chronic elderly patients Design of the APPCARE model, designed to meet the main challenges perceived, such as the fragmented care management and the long and frequent hospital stays of +75 patients Context -adaptation of the model Collection of ex-ante and ex-post data to assess indicators Evaluation of impact and sustainability of the APPCARE model (including costeffectiveness analysis), on the basis of the experimentation results Work performed during the reportingperiod The partners carried out a detailed review of best practices of integrated care and prevention for elderly and multi-morbid patients, both inside and outside the Consortium; in the meantime, they deeply analyzed the current situations in the involved pilot sites (Treviso, Rotterdam and Valencia) in order to better Page 4/20

5 define the existing context in which the experimentation will run. The analysis identified the common challenges the project should address in the field of hospital care, coordinated care and prevention, becoming the driver for the development of the APPCARE model. The model defines a list of general requirements that has been context adapted in the three pilot sites. For each module, the APPCARE model foresees: Regional adaptation in order to answer the needs of different contexts: considering the relevant differences among the three regions participating in the APPCARE project as pilot sites, the procedures have been context-adapted in order to guarantee its validity. Repository of good practices, thanks to a local benchmark analysis to gather all existing resources to be taken into account in the definition of the clinical pathways for patients to follow. Training for professional on the model: Professionals has been trained in order to carry out the experimentation. In addition to this, different professionals have been involved in the data collection process. This needs to be centralized by means of a data collection tool specifically developed for the APPCARE model (task of WP10 Final Impact and sustainability) which is now under construction. The main output achieved so far and their potential impact and use by target group (including benefits) The experimentation phase started in December 2016 with the first enrolments, so currently no analysis on achieved outputs is available. Achieved outcomes compared to the expected outcomes The APPCARE Consortium foresees that the achievement of the mentioned project s objectives will lead to the following potential outcomes: Reduction of functional status loss (according to the patient s clinical trajectory) Page 5/20

6 More appropriate and timely care interventions Reduction of avoidable/unnecessary hospital admission Reduction of hospitalization s adverse outcomes rate Reduction of readmission rate reduction of unnecessary diagnostics and adverse outcomes related to pharmacotherapy increased patient and informal caregivers empowerment and selfmanagement early monitoring of frailty conditions healthcare delivery optimization and savings The experimentation phase started in December 2016 with the first patient s enrolments, so currently no analysis on impact is available. Dissemination and evaluation activitiescarried out so far and their major results All the dissemination efforts already performed or scheduled are completely in line with the internal dissemination strategy agreed by the partners. One of the main dissemination tool is the project website which is now on line with the main information on model development and progresses. Public project documents are available for download and consultation, including the project leaflet. The leaflet illustrates the general requirements of the model, and will be newly released at the end of the experimentation to present project s main achievement. The English version of the leaflet will be translated and printed by the Consortium to be widespread also at national level. The first achievement of the APPCARE project will be presented during the project s public event scheduled in Valencia on June Furthermore, the APPCARE model will be discussed during in a dedicated session of the Italian Psycho-geriatric association congress organized in Florence on March 30th-31st Besides all the activities to grant a high quality of project management, APPCARE foresees an external evaluation task to be performed by a qualified evaluation body to assess effectiveness, efficiency and utility of the project. The market survey to identify a possible external evaluator is ongoing: the team estimates to appoint it by April 2017 at latest. Page 6/20

7 Work package Work Package 1: Coordination of the project Start month: 1 End month: 36 Work Package Leader: ULSS9 Well-functioning and precise management structures are fundamental for a sound project implementation, assuring the quality of the project process and outputs. In the start-up phase, management structures will be made operational and the legal basis of the project will be set up. All partners will contribute to the daily management of the project, coordinated by the LA. The LA will also be responsible of the communication flow, also through the use of web instruments and clearly guidelines shared during the kick-off meeting. Task 1.1 Financial and administrative coordination LHA9 Connection with the EU Project Officer; Submission of expected deliverable according to the project plan, Collection and consolidation of Cost Statements; Distribution of EU contribution among partners. Task 1.2 Operational coordination LHA9 Preparation of a detailed Project Plan This proposal version was submitted by Massimo Calabrò on 25/09/ :59:04 CET. Issued by the Participant Portal Submission Service. Coordination of WPs Leader activity Monitor of the timely project implementation, according to the Project Plan, setting the necessary corrective actions in case of shift. Overall coordination of project meetings Preparation of contractual periodic management reports. Task 1.3 Scientific coordination GRG Creating a Scientific Committee consisting of representatives from each of the involved regions with special expertise in outcome assessment for geriatric interventions, in charge of: - Ease the exchange of experiences among trial s pilot sites - Validate an Ethic Plan describing ethics requirements for each pilot site together with an Ethical check list to guide partner prior and during piloting - Elaborate the Project s scientific dissemination strategy. Work Package 2: Dissemination of the project Start month: 1 End month: 36 Work Package Leader: GRUPPO DI RICERCA GERIATRICA Page 7/20

8 Task 2.1 Dissemination strategy and implementation - GRG. The task leader will coordinate partners contribution on the dissemination strategy at local, national and international level and collect them into a single Dissemination Plan presenting also: Dissemination strategy List of possible events to be attended Project layout and logo to be used Task 2.2 Project website GRG. setting up the project website; defining the web site dissemination strategy, including the related editorial policy and processes maintaining and enhancing the project website. Task 2.3 Project dissemination materials Each partner is in charge of issuing the dissemination materials for key stakeholders (general public, health professionals, etc) Printed materials will be issued in English and translated in Italian, Spanish and Dutch languages. Task 2.4 Scientific communication and publications - GRG Issuing strategy for scientific communication and publications identifying relevant forums and journals Redacting articles for scientific journals in collaboration with local project teams; Submitting articles for peer reviewing and publications on open-access Task 2.5 Mid-Term and Final Conference EMC and LHA9 Organization of the project Mid-Term Conference EMC. Organization of the project Final Conference LHA9 Work Package 3: Evaluation of the project Start month: 1 End month: 36 Work Package Leader: ULSS9 Task 3.1 Quality Assurance Issue of a Quality Plan, detailing the working methods to be used, information flow as well as other standards in use (such as project planning, administration, etc.) Monitor of the proper maintenance of quality requirements; Provide feed-back to the Project Management about possible deviations from project plans or from agreed quality standards. Task 3.2 External evaluation: An external evaluation body with specific public health competences will be subcontracted to assess the project achievement with particular regard to: Effectiveness: The extent to which the project achieved its specific objectives and Page 8/20

9 goals Efficiency: The extent to which the project used its resources efficiently, and provided value for money Utility: The extent to which the project has a potential impact on the main target groups specified, including older citizens, professionals, managers and policy makers and assessment of their awareness on the project. Sustainability: The extent to which the project has led to sustainable changes or benefits that will last after the project has been completed. Task 3.3 Risk analysis and contingency plan A deep risk analysis - including both internal and external risk - will be performed, together with a contingency plan to be monitor during the project lifetime Work Package 4: Best practice analysis Start month: 1 End month: 4 Work Package Leader: Erasmus MC Task 4.1 Analysis of current situations Each pilot site will gather data and describe its own current situation in the management of frail patients, following a template provided by the LA who will coordinate data gathering. This analysis will include best practices already performed in the three main areas of intervention (hospital care, coordinated management care and prevention) at local, national and/or international level. Task 4.2 EU dimension synthesis The LA will issue an EU dimension synthesis on best practices performed in the project involved pilot sites, containing also a wider analysis at EU level (considering practices also from outside the partner's territories) Particular attention will be given to best practices collected by EIPAHA, taking into account the lesson learnt of the studied best practices. This synthesis will to pave the way for the selection of the most appropriate model to be implemented. Work Package 5: Model design and adaptation Start month: 3 End month: 9 Work Package Leader: ULSS9 Task 5.1 Hospital care module creation LHA9 Task Hospital care module adaption in Italy Task Hospital care module adaptation in Spain Page 9/20

10 Task Hospital care module adaptation in Netherlands Task 5.2 Coordinated care management module creation (UVEG) Task 5.2.1coordinated care management module adaptation in Italy Task coordinated care management module adaptation in Spain Task coordinated care management module adaptation in Netherlands Task 5.3 Prevention module creation (EMC) Task Prevention module adaptation in Italy Task Prevention module adaptation in Spain Task Prevention module adaptation in Netherlands Task 5.4 issue of scientific trial protocol(s) GRG Issue the protocol(s) in collaboration with the Scientific Committee. The design will be set up in order to produce novel knowledge with the highest possible level of evidence. Coordinate the presentation to the competent Ethic Committee of each pilot site proving advice in accordance to the agree Ethic Plan Work Package 6: Data interoperability Start month: 4 End month: 33 Work Package Leader: UVEG The Leading Applicant will coordinate the execution at each pilot site of the following tasks: Task 6.1 Communication flows overview: analysis of the existing communication flows in each pilot site, and the related ICT solutions running. Task 6.2 Interoperability solution: implementation of an ICT solution to be integrated in the already existing IT systems in order to allow or enhance data exchange. This solution must be compliant with IT protocols to ensure data protection. Task 6.3 Interim evaluation of interoperability solution: at month 21, an interim evaluation of the interoperability solution performance will be performed. An updated version will be release accordingly. Task 6.4 Final evaluation of interoperability solution: at month 34, a final evaluation report of the interoperability solution, including final recommendations will be issued. Page 10/20

11 Work Package 7: Hospital care module implementation Start month: 10 End month: 33 Work Package Leader: ULSS9 Task 7.1 Pilot sites implementation plan and overall coordination LHA9 Issue of a an implementation plan taking into account the Intervention mapping approach (Health Educ Behav 1998;25(5):545-63). Task 7.2 Care givers involvement Actions will be set up to inform and involved, also through the setting of collaboration partnership if necessary. Actors should be aware of the following aspects of the collaboration to be taken into account (a) collaboration/co-location of health and social care (J Interprof Care 2005;1:22-34); (b) include and value the deployment of multidisciplinary health and social professionals in addition to geriatric physicians and general practitioners (JAMA 2004: ). Task 7.3 Health professional training At each site, the involved professionals and personnel will be trained to use the supporting protocols, models and when appropriate supporting IT modules. It is envisaged to organize training common session(s) on the entire APPCARE model, management attended by all the health professional involved in WP7, WP8 and WP9 - followed by specific session(s) focused on the hospital care. Task 7.4 Study format From month 10 onwards, during 15 Months, citizens/patients who are 75 years and older (many of them with multimorbidity, frailty or disability) will be informed and invited to join the project and provide informed consent; also carers/family will be informed people will be involved in the project. They will join the project during 9 months for hospital care interventions concomitantly with WP8-9. Task 7.5 Intermediate analysis (LHA9): An intermediate analysis on collected data will be carried out 12 month after the start of the implementation. Task 7.6 Data collection and final results (LHA9) A final analysis on collected data about the hospital module will be carried out. This analysis will feed the final impact analysis foreseen in WP 10. Work Package 8: Coordinated care management module implementation Start month: 10 Page 11/20

12 End month: 33 Work Package Leader: UVEG Task 8.1 Pilot sites implementation plan and overall coordination UVEG Issue of a an implementation plan taking into account the Intervention mapping approach (Health Educ Behav 1998;25(5):545-63). Task 8.2 Care givers involvement LHA9, UVEG, EMC Actions will be set up to inform and involved, also through the setting of collaboration partnership if necessary. Actors should be aware of the following aspects of the collaboration to be taken into account (a) collaboration/co-location of health and social care (J Interprof Care 2005;1:22-34); (b) include and value the deployment of multidisciplinary health and social professionals in addition to geriatric physicians and general practitioners (JAMA 2004: ). Task 8.3 Health professional training LHA9, UVEG, EMC At each site, the involved professionals and personnel will be trained to use the supporting protocols, models and when appropriate supporting IT modules. It is envisaged to organize training common session(s) on the entire APPCARE model, management attended by all the health professional involved in WP7, WP8 and WP9 - followed by specific session(s) focused on the coordinated care management module. Task 8.4 Study format From month 10 onwards, during 15 Months, citizens/patients who are 75 years and older (many of them with multimorbidity, frailty or disability) will be informed and invited to join the project and provide informed consent; also carers/family will be informed people will be involved in the project. They will join the project during 9 months for coordinated care interventions concomitantly with WP7-9. Task 8.5 Intermediate analysis LHA9, UVEG, EMC An intermediate analysis on collected data will be carried out 12 month after the start of the implementation. Task 8.6 Data collection and final results UVEG A final analysis on collected data about the coordinated care module will be carried out. This analysis will feed the final impact analysis foreseen in WP 10. Work Package 9: Prevention module implementation Start month: 10 End month: 33 Work Package Leader: Erasmus MC Page 12/20

13 Task 9.1 Pilot sites implementation plan and overall coordination - EMC Issue of a an implementation plan taking into account the Intervention mapping approach (Health Educ Behav 1998;25(5):545-63). Task 9.2 Care givers involvement Actions will be set up to inform and involved, also through the setting of collaboration partnership if necessary. Actors should be aware of the following aspects of the collaboration to be taken into account (a) collaboration/co-location of health and social care (J Interprof Care 2005;1:22-34); (b) include and value the deployment of multidisciplinary health and social professionals in addition to geriatric physicians and general practitioners (JAMA 2004: ). Task 9.3 Health professional training At each site, the involved professionals and personnel will be trained to use the supporting protocols, models and when appropriate supporting IT modules, and apply these protocols to offer the locally established medical and social preventive, evidence-based preventive interventions. These are offered actively to patients included in the pathways of WP7 and WP8, The preventive intervention include evidence-based and locally available preventive interventions targeting: (a) screening and management of frailty and specific actions to prevent frailty such as physical exercise and activities against social isolation and loneliness, (b) use of informal health and social support in addition to formal services, (c) evidence-based approaches and available modules for active management of polypharmacy and adherence, and (d) available multifactorial programs for fall prevention. Task 9.4 Study format From month 10 onwards, during 15 Months, citizens/patients who are 75 years and older (many of them with multimorbidity, frailty or disability) will be informed and invited to join the project and provide informed consent; also carers/family will be informed people will be involved in the project. They will join the project during 9 months for prevention interventions concomitantly with WP7-8. Task 9.5 Intermediate analysis (EMC): an intermediate analysis on collected data will be carried out 12 month after the start of the implementation Task 9.6 Integration with WP7-8: actions set up to grant a coordinated care during the all patient s care path. Task 9.7 Data collection and final results (EMC) Work Package 10: Impact and Sustainability Analysis Start month: 21 End month: 36 Work Package Leader: UVEG Page 13/20

14 Task 10.1 Development of a common database Creating a central database for each pilot site s data collection. Task 10.2 Data management Selecting within each of pilot sites a member responsible for carrying out the trial s data management and produce the corresponding analysis. Task 10.3 Analysis and reporting of results Assisting local project teams in analysis and results reporting activities Carrying out a centralized analysis of economic outcomes. Task 10.4 Sustainability of the model Final impact assessment Task 10.5 Scalability of the model Detailed Scalability Plan Identification of further model adopter Page 14/20

15 COORDINATOR, LEADER CONTACT AND PARTNERS COORDINATOR AZIENDA UNITA LOCALE SOCIO SANITARIA N 9 DI TREVISO (ULSS9) Piazzale Ospedale Treviso Italy WEBSITE: Project leader contact Name: CALABR Massimo progettifinanziati@ulss.tv.it Phone: PARTNERS UNIVERSITAT DE VALENCIA Street: AVENIDA BLASCO IBANEZ 13 City: VALENCIA Country: Spain Website: UNIVERSITAT DE VALENCIA Street: AVENIDA BLASCO IBANEZ 13 City: VALENCIA Country: Spain Website: UNIVERSITAT DE VALENCIA Street: AVENIDA BLASCO IBANEZ 13 City: VALENCIA Country: Spain Website: Page 15/20

16 UNIVERSITAT DE VALENCIA Street: AVENIDA BLASCO IBANEZ 13 City: VALENCIA Country: Spain Website: ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM Street: 's Gravendijkwal 230 City: 3015 CE ROTTERDAM 2040 Country: Netherlands Website: ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM Street: 's Gravendijkwal 230 City: 3015 CE ROTTERDAM 2040 Country: Netherlands Website: ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM Street: 's Gravendijkwal 230 City: 3015 CE ROTTERDAM 2040 Country: Netherlands Website: ERASMUS UNIVERSITAIR MEDISCH CENTRUM ROTTERDAM Street: 's Gravendijkwal 230 City: 3015 CE ROTTERDAM 2040 Country: Netherlands Website: GRUPPO DI RICERCA GERIATRICA Street: Via Fratelli Lombardi City: Brescia Country: Italy Website: Page 16/20

17 GRUPPO DI RICERCA GERIATRICA Street: Via Fratelli Lombardi City: Brescia Country: Italy Website: Page 17/20

18 OUTPUTS APPCARE Layman version GRUPPO DI RICERCA GERIATRICA Expected on: 01/07/2019 A short (e.g. 10 pages) version of the final report, written for the interested public as a targeted group. Final report ULSS9 Expected on: 01/07/2019 This report describes the project implementation and the results achieved. The deliverables are annexed. External evaluation final report ULSS9 Expected on: 01/05/2019 a report on the project performances, addressing the issues described in task 3.2 and giving final recommendations on the issues addressed with particular regards to target group s awareness, will be prepared. This document will feed the overall impact assessment foreseen in WP10 tasks. Report on interoperability solution UVEG Expected on: 01/04/2018 A final evaluation report of the interoperability solution, including final recommendations will be issued. This document will feed the overall impact assessment foreseen in WP10 tasks. Page 18/20

19 Hospital care model implementation ULSS9 Expected on: 01/04/2019 Plan for execution of the hospital care module for each of the three sites, and interim and final evaluation of the experimentation. Coordinated care model implementation plan UVEG Expected on: 01/04/2019 Plan for execution of the coordinated care module for each of the three sites, and interim and final evaluation of the experimentation. Prevention model implementation plan Erasmus MC Expected on: 01/04/2019 Plan for execution of the prevention module for each of the three sites, and interim and final evaluation of the experimentation. Final impact assessment and sustainability UVEG Expected on: 01/07/2019 Final impact assessment and sustainability of the project: collecting input from other WPs final deliverables (external evaluation reports, risk contingency, etc.), an overall overview of the project impact will be issued. Interim Progress Report and Financial Statement ULSS9 Published on: 15/06/2017 Page 19/20

20 Powered by TCPDF ( This report describes the activities carried out, milestones and results achieved in the first half of the project. Deliverables can be attached as annexes APPCARE model ULSS9 Published on: 31/03/2017 the selected module related to the setting of the 3 moduled (hospital care, coordinated care management, prevention) will be described, together with the adaptations to be set in each pilot site. APPCARE leaflet GRUPPO DI RICERCA GERIATRICA Published on: 30/09/2016 Project dissemination materials will be produced, included the project leaflet to be newly released at month 24. APPCARE website GRUPPO DI RICERCA GERIATRICA Published on: 02/12/2015 Project web-site will be set up, mainteined and enhanced. The website dissemination strategy and the editorial policy will be assessed and defined. EU synthesis report Erasmus MC Published on: 02/12/2015 document describing pilot sites situations, best practices inside and outside the Consortium, representing the knowledge base propaedeutic for the model construction. Page 20/20