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Poster Abstracts

Health and Social Care systems reaching out to vulnerable populations with chronic conditions: the EU-project EFFICHRONIC


Marta Pisano González ,

DG Public Health Asturias Health Government, ES
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An Boone,

Foundation for the Promotion of Applied Scientific Research and Technology in Asturias FICYT, ES
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Arturo Alvarez-rosete

New Health Foundation, ES
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The quest for integrated care has often been depicted as “crossing the boundaries”, going “beyond silos” or “cutting across” multiple systems, services, providers and settings. More recently, these health system and organization-centred concerns have been complemented with person-centred perspectives that focus on the needs of service users, their families and communities and what matters most for them.

This new emphasis implies a new understanding of the scope of responsibilities of care systems: rather than waiting for people to attend the system to receive integrated care, it involves actively seeking those who might need it most and which are usually “hard-to-reach”. Person-centred approach urges systems and services to be more proactive and reach out to those vulnerable populations who are hard-to-reach. The chances of reaching these groups increase when organisations and services from all sectors align, coordinate their actions and work together. 

EFFICHRONIC: The EU-funded project EFFICHRONIC aims to empower vulnerable hard-to-reach patients and caregivers to self-manage their chronic conditions. The project seeks to provide evidence on the positive return of investment and cost-efficiency of the application of the Chronic Disease Self-Management Programme (CDSMP) in different regions of 5 European countries (France, Italy, The Netherlands, Spain and UK) with a particular focus on the health-related, medical, social, cultural and economic factors linked with a higher burden of chronic disorders in Europe.

Targeted Population: EFFICHRONIC aims at implementing the CDSMP in those groups of society that are most exposed to the negative effect of the social determinants of health. The EFFICHRONIC project uses the term “vulnerable” to refer to individuals that are not fully socially integrated and risk falling into social exclusion, either due to socio-economic hardship or due to physical or psychological reasons (the chronically ill, the disabled, the frail elderly or  people suffering from mental health problems).  A total sample of 2000 individuals receives the CDSMP programme.


Acknowledgements: The project EFFICHRONIC has received funding from the European Union’s Health Programme (2014-2020) under Grant Agreement 738127.

Workshop Programme Outline: We propose short presentations, followed by a half an hour discussion:

EFFICHRONIC Overall Project approach: by Marta Pisano and An Boone (DG Public Health, Asturias Regional Government. Spain). 15 minutes

The identification of vulnerable groups/individuals in the 5 countries through a multidimensional analysis and stratification methodology (Selfy-Multidimensional Prognostic Index): by Alberto Pilotto (Ente Galliera Hospital. Italy). 10 minutes

Intersectoral strategies used to recruit vulnerable populations: by Yves-Marie Pers (Centre Hospitalier Universitaire Montpellier. France).Preliminary results after a year and a half into the EFFICHRONIC project. 10 minutes

Project Evaluation framework:  Siok-Swan Tan (Erasmus University Medical Centre. The Netherlands). A rigorous methodology, involving 5 different settings will provide evidence on the impact of EFFICHRONIC. 10 minutes

Methodology of Internal Quality control: by Barbara Branchini (Polibienestar Research Institute. Spain). 10 minutes

Communication and Dissemination: by Graham Edward Baker (Quality Institute for Self-management education and training. UK). 10 minutes

Policy recommendations and guidelines to scale up the most effective outreach strategies to other settings in Europe: by Arturo Alvarez. 10 minutes

How to Cite: Pisano González M, Boone A, Alvarez-rosete A. Health and Social Care systems reaching out to vulnerable populations with chronic conditions: the EU-project EFFICHRONIC. International Journal of Integrated Care. 2017;19(4):413. DOI:
Published on 08 Aug 2017.


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