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Scaling-up Principles Leading to a Persistent Health Ecosystem, by a Coherent Sequence of Integrated Care Programmes


Angelo RossiMori

Cnr-irpps, Italy, IT
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Extensive experience is available in implementing successful Integrated Care Programmes; however, too many initiatives are independently designed and limited in scope to a specific topic, lacking a global vision.

Policy context

Any Integrated Care Programme should arise inside a regional multi-annual roadmap, according to a long-term policy to achieve a pervasive transformation of a regional health ecosystem.

To this end, our study analysed the transformative power of 30 Service Delivery Models, previously co-produced by the Author with stakeholders engaged in the respective Integrated Care Programmes.

For each Programme, a toolkit allowed to assess the ""Transformation Index"" of the Service Model, the intrinsic deployment difficulty and the attitude to support the policy.


Twenty-two models of our sample were considered capable of laying the foundation for any other Programme; they were assigned to three Basic Themes:

- long-term follow-up of complex chronic conditions (9 cases);

- long-term follow-up of frailty and mobility impairment (8 cases);

- short-term follow-up after a severe health-related event (5 cases).

In particular, the first two Themes can establish a collaborative atmosphere among professionals and an active participation of citizens/patients on managing their health, yielding a high Value.

The other eight cases were examples addressing Complementary Themes, classified as: remote follow-up of implanted cardiac devices, treatment of depression, and family nurse supporting physician’s e-visit; several good practices can hint many other successful Themes.

The study suggested a number of systemic principles about Programmes co-design in a national / regional Roadmap; among them:

  a) an early, wide deployment of Basic Themes may allow a better harmonisation of further Programmes in the Ecosystem.

  b) the strategic priority of a Programme (in a given moment, in a given local context, in a given regional Roadmap) depends on the following criteria:

    - it is widely replicable, to yield a massive scaling up;

    - it is modular, to allow a progressive growth;

    - several other localities are mature to start deploying the related health transformation;

    - costs and outcomes are measurable in the short/medium period for timely evaluation and tuning;

    - in case of innovation procurement, a contribution to its outcomes can be attributed to the suppliers;

  c) commercially available technologies applied to the Basic Themes usually can establish a robust platform to satisfy further additional needs;

  d) some Complementary Themes could yield a high Value; however, by definition they provide less support in ecosystem building than Basic Programmes.


These principles can be applied to any regional Roadmap:

- any Programme should be coherent with previous and future Programmes;

- existing technologies can enable significant services transformations;

- the deployment of Basic Themes could induce a massive “snowball effect”, also outside the involved jurisdictions, with a high impact on population health and Digital Market.


The Basic Themes support the deep transformation of organisational processes, promote a collaborative atmosphere among actors and across settings, and set up an interoperable technological backbone, in the spirit of propagating a Disruptive Health Innovation in a Health Ecosystem.

How to Cite: RossiMori A. Scaling-up Principles Leading to a Persistent Health Ecosystem, by a Coherent Sequence of Integrated Care Programmes. International Journal of Integrated Care. 2022;22(S1):126. DOI:
Published on 08 Apr 2022.


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