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Table 1 Overview of the focus of the five KT cases in the SCIROCCO project

From: The transfer of knowledge on integrated care among five European regions: a qualitative multi-method study

Location of KT cases 1 to 5 (transferring region)Focus of KT caseDescription of the focus of the KT case
1. PugliaGood practice in telemonitoringHospital@Home Good Practice is designed as a technological support for already structured activities in home care. The main objective is to reduce hospitalisation and re-hospitalisation and to improve the quality of care for patients at home. In addition, the objective is to:
Reduce the number of patients with heart disease, diabetes and other chronic diseases in the process of instability
Activate protected de-hospitalisation
Optimise the therapy and diagnosis according to international guidelines.
The aim is to implement a new type of telemonitoring, based on continuous collaboration and patient monitoring by different professionals and different users. Patients are telemonitored by their General Practitioners by using the innovative home and health monitoring technological solution (H&H Hospital@Home). This solution is able to detect the main clinical and instrumental parameters in addition to the therapeutic administration, based on oxygen and bronco-aspiration. It is allocated at the patients’ home and it is permanently interconnected with the General Practitioner and/or Specialist, by computer, telephone, tablet and other devices.
At the same time, there is a central monitoring room at the hospital for all patients and all devices located at their home. All clinical parameters of patients are stored on a dedicated server, respecting the rules for the respect of privacy. The system allows the healthcare professionals (neurologists, pulmonologist, cardiologists, diabetologists, etc) to monitor and speak with patients remotely. The patients can also activate the visit of the healthcare professionals in their homes. In addition to real-time monitoring of physiological parameters, the healthcare professionals can also monitor the physical and technical characteristics of home device. As a result, it is possible to deliver therapy to the patient remotely.
2. Basque CountryGood practice in advance care planningAdvance care planning (ACP) is a voluntary process of discussion between an individual and care providers about future care, irrespective of discipline. The aim is to guarantee patients’ right to take decisions about their own care as well as to have those decisions respected when time comes.
The goal of this Good Practice is to promote ACP approach to the Basque population, particularly to chronic conditions population. The idea is to adjust end of life care to meet patients’ preferences and improve decision making processes.
Three stages were defined when designing the Good Practice:
Diagnostic stage in order to identify the population that could benefit from the ACP
Therapeutic stage in order to develop the intervention
Evaluative stage in order to assess both the impact of the Good Practice and the Good Practice itself.
The core intervention consists of two individual semi structured interviews with the patient and one or two members of patient family and/or friends. The interviews are carried out by the patient’s General Practitioner (GP) and the community nurse. The first meeting aims mainly at introducing the subject (Advanced Directives) and inviting the patient to reflect on his/her preferences regarding the care. The second interview then focuses on the discussions of the specific issues related to the patient and his/her clinical characteristics and situation. Participants write down an advance directive according to their values, health conditions and preferences. The GP and/or community nurse assist with this process.
Every healthcare professional can access the Advance Directive using the Basque Country’s Integrated Electronical Health Record. As ACP is considered an evolutive process, the patient can change opinion and modify its preferences whenever is needed.
3. ScotlandDimension of the SCIROCCO tool: Innovation ManagementHealth innovation is an exciting and dynamic area with a range of stakeholders from all sectors working collaboratively to position Scotland as a world leader in health innovation, contribute to a thriving economy and support faster adoption of innovation across health and social care. Innovation is defined in Scotland as the invention, development, production and use of products, medicines, therapeutics, approaches and supporting services which create the opportunity to make major improvements to health and healthcare.
Scotland is already recognised as an innovation nation. The recently refreshed 2017 Scottish Life Sciences Strategy sets out strategic priorities for the sector to fulfil Scotland’s ambitions to be a world-leading entrepreneurial and innovative nation.
The Scottish Government has outlined its commitment to innovation with recently published Scotland Can Do – Boosting Scotland’s Innovation Performance: An Innovation Action Plan for Scotland (January 2017) and more specifically to health innovation within the Health and Social Care Delivery Plan (December 2016) and recently published Digital Health and Care Strategy (April 2018).
A range of initiatives and partnerships are already well established (Innovation Ecosystem) as part of the overall drive to support health innovation and its formalisation in Scotland
4. ScotlandGood
practice(s) in
Third Sector
The “third sector” in Scotland is made up of non-governmental and non-profit organisations, from grassroot community groups and village hall committees to social enterprises and registered national charities. It is often also described as the voluntary sector, not-for-profit, charity sector, social economy, social enterprise sector, NGOs (non-government organisation) or civil society.
The traditional idea of charities as benevolent organisations simply there to help the poor is being replaced by a modern, progressive, third sector which carries out an enormous range of activities to improve people’s lives. It does it by:
-Supporting people through social care, health services and employability programmes;
-Empowering people by campaigning and advocating for minority and disadvantaged groups in our society;
-Bringing people together through social activities, local clubs and community centres;
-Enabling better health and wellbeing through medical research, addiction services, sport facilities and self-help groups;
-Improving our environment through conversation of our land and heritage, and regeneration of our communities.
In Scotland, there is a legal framework in place for the engagement of third sector in the provision of integrated care. The Public Bodies (Joint Working) (Scotland) Act 2014 is the legislative framework for the integration of health and social care services which requires the integration of the governance, planning and resourcing of adult social care services, adult primary care and community health services and some hospital services. Other areas such as children’s health and social care services, and criminal justice social work can also be integrated.
5. NorrbottenDimension of SCIROCCO tool: Information and eHealthA need to introduction technology enabled solutions is widely recognised among all stakeholders involved. There is a clear plan and strategy in place to support widespread implementation of eHealth services. Patients are widely supported and encouraged to manage their own care and participate actively in the decision-making process through the access to electronic health records and relevant health information.
National ICT solutions to increase patients´ access to their medical records have been developed and implemented in Norrbotten Region on a large scale. There are also national ICT solutions to support patients´ participation in the management of their own care but not fully implemented yet. A share of patient related information between different care providers is facilitated at the regional level. Norrbotten Region has also very well progressed with building the ICT solutions on existing platforms and infrastructure and has thus created new services to empower patients and ensure their ability to participate in the decision-making on their care as well as supporting self-care. However, scalability of these solutions still remains the issue.