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What does it take to make integrated care work?


Helen Schonenberg ,

Steffen Pauws,

Ioanna Chouvarda,

Cristina Bescos,

Stan Newman,

Josep Roca,

Stefan Störk,

David Barrett,

John Cleland,

Andrea Pavlickova,

Montse Moharra,

Marco Nalin,

Maarten Lahr,

Esteban de Manuel Keenoy


Within the EU, there are 10 million people with chronic heart failure (CHF), 20 million people with chronic obstructive pulmonary diseases (COPD), and 60 million people with diabetes (DM). These three conditions alone cost the EU healthcare systems around €125 billion a year.

Care coordination and telehealth (CC&TH) services are an effective way to treat these patients in their homes. However, the adoption of these services is relatively slow. A primary reason that is hindering the adoption is the integration of these services into the care delivery structures of exiting routine care practices.

So far, CC&TH has been directed at improving health outcomes, administrative efficiency and cost effectiveness. The Advancing Care Coordination & Telehealth Deployment (ACT) Programme is the first to explore the organisational and structural processes needed to successfully implement care CC&TH services on a large scale. This EU-funded programme includes a consortium of clinical experts, universities, industry partners, and authorities from 5 leading healthcare EU regions. The objective of the ACT programme is to analyse what needs to be done to effectively integrate CC&TH services and identify best practices in Europe.

Five leading EU healthcare regions with broad experience in CC&TH care delivery have shared their experiences of program deployment and provided data for the assessment. Each region has a population of at least 3000 patients (CHF, COPD and DM). The participating regions are Lombardy (IT), Basque Country (ES), Catalonia (ES), Northern Netherlands (NL), and Scotland (UK).

The ACT evaluation framework considers final outcomes on efficiency and efficacy, as well as process outcomes to measure the integration of the CC&TH deployment into routine care with respect to stratification, care coordination and workflow optimization, patient adherence, and staff engagement. Data (qualitative and quantitative) were collected at baseline (month 6) and during several iterations (month 14, 18 and 24). Data collection, storage, analysis and visualization is supported an evaluation engine.

There are yet no generally accepted indicators for measuring the successful deployment of CC&TH at European level. Hence, such data is not easily shared or compared. Such limitations need to be acknowledged when interpreting results.

Despite marked differences between participating programmes (e.g. target population, maturity level, funding schemes), a common way to present and evaluate these programmes with the terminology, data models and its evaluation framework and engine was developed during the ACT programme. This allowed the presentation and comparison of programmes in a common framework, where (relative) differences were highlighted, and enabled generalization of findings and knowledge transfer.

Over 2500 survey responses and more than 90 datasets were collected and analysed. The insights, conclusions, recommendations and best practices were then incorporated into a ‘cookbook’ for large-scale deployment of CC&TH, from which some high level examples are given below.

Our findings suggest that for staff engagement it is necessary to provide interventions in training, early engagement of staff, communication feedback loops, and recognition of professional expertise. Tailored adherence strategies that address the patient’s needs are required to achieve adherence, not only for clinical needs, but also social support and socio-economic needs. Furthermore, health risk assessment should employ a population-based approach. Although some of these findings may be appear intuitive or self-evident, it is important to stress that there actually is evidence for these findings. They are based on data from various operational deployments across Europe. Further details and examples are available in the cookbook and online (

The assessment process using the evaluation framework and engine in the regions has been useful for the regions. Some examples of their practical impact are:

- demonstration of good program outcomes to policy makers,

- evidence of shifts towards primary care in utilization, but not in resources,

- knowledge transfer between regions after highlighting relative strengths and weaknesses, and

- benchmarking of programs within a region.

Due to their complexity, each CC&TH deployment is unique. Despite the differences, the methodology and tools to assess these deployments, and a common way to present their relative strengths and weaknesses was successfully developed within the ACT programme. This approach has proven to be effective in creating knowledge transfer within and across the regions.

As a next step, the ACT consortium intends to apply the framework and tools to monitor progress of deployment performance during iterative process improvement cycles. In addition, the consortium seeks to promote the structured development of generally accepted quality indicators for successful deployment of care strategies across Europe. 

How to Cite: Schonenberg H, Pauws S, Chouvarda I, Bescos C, Newman S, Roca J, et al.. What does it take to make integrated care work?. International Journal of Integrated Care. 2016;16(6):A113. DOI:
Published on 16 Dec 2016.


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