STATE OF PLAY OF ACTION GROUP B3 · 2015-12-21 · B3 Action Group on Replicating and Tutoring Integrated Care for Chronic 7 Diseases, Including Remote Monitoring at Regional Level

STATE OF PLAY OF ACTION GROUP B3

EUROPEAN INNOVATION PARTNERSHIP ON ACTIVE AND HEALTHY AGEING

Replicating and Tutoring Integrated Care for Chronic Diseases, Including Remote Monitoring at Regional Level

Luxembourg: Publications Office of the European Union, 2015

Electronic version:ISBN 978-92-79-52728-9doi:10.2875/56890Catalogue number: EW-01-15-835-EN-N

Paper version:ISBN 978-92-79-52727-2doi:10.2875/940995Catalogue number: EW-01-15-835-EN-C

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1B3 Action Group on Replicating and Tutoring Integrated Care for Chronic Diseases, Including Remote Monitoring at Regional Level

November 2015

AuthorsAG B3 Coordinators 2012-2015

Stella Tsartsara, AG B3 Promoter 2015-2016 (CSA PROEIPAHA)

Anna Kivilehto, AG B3 Secretariat Support Service 2015-2016 (CSA PROEIPAHA)

With many thanks to all the AG B3 Partners who provided inputs, data and suggestions for this publication.

DisclaimerThe information and views set out in this publication are those of the authors and do not

necessarily reflect the official opinion of the Commission. The Commission does not guarantee the accuracy of the data included. Neither the Commission nor the Action Groups may be held

responsible for the use which may be made of the information contained therein.

© European Union, 2015. All rights reserved. Certain parts are licensed under conditions to the EU.

Reproduction is authorised provided the source is acknowledged.


November 2015

Contents

1. Executive Summary ...................................................................................................................... 5

2. Rationale of Replicating and Tutoring Integrated Care for Chronic Diseases, Including Remote Monitoring at Regional Level Action Group ................................ 6

3. Action Group Description .......................................................................................................... 7

3.1 Role and Objectives ..................................................................................................................... 7

3.2 Governance & Coordination ...................................................................................................... 7

3.3 Structure ......................................................................................................................................... 8

3.4 Action Areas of the AG ................................................................................................................ 9

3.4.1 Action Area 1: Organisational Models ...................................................................... 10

3.4.2 Action Area 2: Change Management ...................................................................... 10

3.4.3 Action Area 3: Workforce Development ................................................................... 10

3.4.4 Action Area 4: Risk Stratification ................................................................................. 11

3.4.5 Action Area 5: Care Pathways ................................................................................... 11

3.4.6 Action Area 6: Workforce development ................................................................... 12

3.4.7 Action Area 7: ICT and Teleservices ........................................................................... 12

3.4.8 Action Area 8: Finance and Funding ......................................................................... 12

3.4.9 Action Area 9: Communication and Dissemination ................................................ 13

4. Activities & Achievements ......................................................................................................... 14

4.1 General Results ............................................................................................................................. 14

4.2 Achievements of the collaborative work .................................................................................. 15

4.3 Key messages and lessons learned ............................................................................................. 18

5. Conclusions and Future Activities .......................................................................................... 20

6. Annexes ............................................................................................................................................ 21

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B3 Action Group on Replicating and Tutoring Integrated Care for Chronic Diseases, Including Remote Monitoring at Regional Level

List of Figures

Figure 1. Governance Structure of the B3 Action Group ....................................................... 8

Figure 2. Action Areas of the B3 Action Group ....................................................................... 9

Figure 3. B3 Toolkit Framework .................................................................................................. 15


November 2015

1. Executive Summary

Local implementation is both the foundation and aspiration of the work of the B3 Action Group. B3 members are implementing chronic disease management programmes in 44 regions; and are focussing on scaling up and replication of their practices to reach the target of 50 regions, and cover 10% of the target population.

The expertise of the B3 Action Group is reflected in a rich collection of over 100 good practices, collected throughout 2013-2015.

Over the last 3 years, B3 members have worked together to develop practical tools:

• The B3 Maturity Model, that functions as a self-assessment tool that guides and supports regions on how to improve their capacity to deploy integrated care services.

• Validated medical guidelines in respiratory diseases have been developed, through collaboration with health professionals, public authorities and patient organisations, into an integrated care pathway for respiratory diseases.

• Experts collected and analysed tools for risk stratification of the population for optimised and targeted care, and make these available for organisations that are planning to develop or improve their systems.

• A Citizen Empowerment Framework helped to develop common understanding and shared vision for integrated health and social care services that centres around the patients and their communities.

The B3 Action Group has worked in close collaboration with a number of EU funded projects, to provide input to the development

and dissemination of their deliverables, including SmartCare, Beyond Silos, Care Well, ASSEHS, ACT, Momentum, Project Integrate and links with the EU Joint Action on Chronic Diseases.

B3 has stimulated inter-regional cooperation, formalised in the form of Memoranda of Understanding, for example between Scotland and the Basque Country, as well as the development of regional networks for active and healthy ageing in Greece, Puglia and Languedoc-Roussillon regions.

The Group has been working laterally and collaboratively on joint work on innovative procurement and interoperability together with Action Group C2 on Interoperable Independent Living Solutions, as well as identifying synergy activities across the six Action Group on patient empowerment.

B3 Action Group members have presented at, a series of high-level European and regional conferences / workshops and participated in exchange visits to promote integrated care on health agenda.

In addition, the B3 Action Group organised two webinars on Change Management and the B3 Maturity Model. Action Group members have produced three articles on change management, one article on the B3 Maturity Model and 22 articles on integrated care pathways were published.

In addition, by providing evidence and inspiration for policy-making, the Group has contributed to ensuring that integrated care is on the European agenda as one of the most promising solutions to assure the sustainability of the systems for health and social care.

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2. Rationale of Replicating and Tutoring Integrated Care for Chronic Diseases, Including Remote Monitoring at Regional Level Action Group

The increasing complexity of health problems, and specifically of chronic conditions, demands overcoming the fragmentation of today’s systems, where different providers deliver separately social care and healthcare services. “Integrated care” models move the system a step further, by harmonising and coordinating the management, organisation and delivery of social and health care services along the whole health promotion and care chain.

The introduction of the integrated care approach sees a shift from reactive care to preventive, proactive and patient-centred care and from institutional to community, home based care.

This delivers benefits such as the reduction in unnecessary hospitalizations, the potential to better handle chronic care needs, as well as efficiency gains and more sustainable and optimised use of resources and more efficient care throughout the whole care system. Putting the needs of the patients in the centre implies the development of integrated care models that are multidisciplinary, well-coordinated and accessible, as well as anchored in community and home care settings. Ultimately, this will make it possible for citizens to be an integral part of the system, as co-producers of health and social care.The Strategic Implementation Plan (SIP)

of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) recognises the need of promoting people-oriented, demand-driven innovation in smart investments, which brings tangible and proven benefits to end-users, helps health and care systems to contain costs and unlocks business opportunities. There is a unique opportunity to bring better health to European citizens, to bring to market innovative products and services, and to establish more sustainable health and care systems.

The B3 Action Group on Integrated Care was formed to support the implementation of SIP and triple win for Europe by addressing the Priority Action Area: Capacity building and replicability of successful integrated care systems based on innovative tools and services, under Pillar 2 “Care and Cure”.

The Action Group aims to reduce the avoidable / unnecessary hospitalisation of older people with chronic conditions, through the effective implementation of integrated care programmes and chronic disease management. The Group builds on services that are currently operational and on on-going activities in pilot initiatives, programmes and standards, and aims for the further deployment of services in a significant number of regions.


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3. Action Group Description

3.1 Role and Objectives

The B3 Action Group was established to develop a response for Integrated Care to the challenges set by the Strategic Implementation Plan (SIP) of the EIP on AHA. The overall objective of the B3 Action Group on Integrated Care is stated in the EIP on AHA Operational Plan of November 2011 as:

“Reducing avoidable/unnecessary hospitalisation of older people with chronic conditions, through the effective implementation of integrated care programmes and chronic diseases management models that should ultimately contribute to the improved efficiency of health systems”.

The SIP envisaged that B3 activities would result in the achievement of the following targets:

• By 2015: Availability of programmes for chronic conditions/case management (including remote management/monitoring) serving older people in at least 50 regions, available to at least 10% of the target population (patients affected by chronic diseases in the regions involved).

• By 2015-2020: Based on validated evidence-based cases, scale-up and replication of integrated care programmes serving older people, supported by innovative tools and services, in at least 20 regions in 15 Member States.

The B3 activities selected for implementation, have been based not only on strategic priorities defined in the SIP but also on direct commitments made by participating stakeholders (B3 Action

Group members), taking into consideration their strategic priorities, resources and capacities. In other words, the activities of B3 should help European regions and delivery organisations to implement chronic care and integrated care programmes; make integrated care accessible to wider populations and maximise the use of innovative tools and services. The B3 Action Group builds on services that are currently operational and on on-going activities in pilot initiatives, programmes and standards, and aims for the further deployment of services in a significant number of regions.

3.2 Governance & Coordination

At the first meeting of the B3 Action Group (2012), it was agreed that a Co-ordination Group should be set up to oversee the development and implementation of the B3 Action Plan. NHS 24 (The Scottish Centre for Telehealth and Telecare) agreed to lead, facilitate and co-ordinate the activities of the B3 Action Group by chairing the B3 Co-ordination group from July 2012. Professor George Crooks, NHS 24 Scotland, UK was appointed as Chair of the Co-ordination group.

The B3 Co-ordinattion Group agreed to be responsible for:

• The development and implementation of the B3 Action Plan, in consultation with the European Commission and by delivering upon agreed individual actions.

• Ensuring that the views and inputs of all B3 Action Group members are reflected in the development and implementation of the Action Plan.

• Leading, facilitating and co-coordinating the activities of the B3 Action Areas.

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• Plan, direct and progress the activities of the B3 Action Areas,

With regard to the governance of the Group, it was agreed that a collaborative governance model would be the most appropriate – voluntary grouping of independent organisations that committed

and collaborating for mutual gain.

The B3 collaborative approach has underpinned the following principles of work:

• It is a new way of doing business at a

results locally: the focus will be on delivery and outcomes.

• It involves “co-production” with other committed partners.

• and we expect to celebrate differences,

• The business of Collaborative is handled in an inclusive and transparent manner. All information is in the public domain.

3.3 Structure

As of November 2015, the B3 Action Group is made up of over 450 participants representing 150 regions, sub-national administrations, delivery organisations, patient/user and carer organisations, academic institutions, and industry and member organisations.

A list of the current B3 commitments is included in Annex 2 of this document.

Figure 1. Governance Structure of the B3 Action Group

B3 Action Group

Members

B3 Co-ordinator Name Organisation

George Crooks NHS 24, Scotland, UK

Donna Henderson NHS 24, Scotland, UK

Albert Alonso Hospital Clinic Barcelona, Spain

Toni Dedeu Digital Health Institute, Scotland, UK

Cristina Bescos Philips, Germany

Magdalena Rosenmoller

IESE Business School, Barcelona, Spain

Esteban de Manuel Kronikgune, Basque Country, Spain

Jean Bousquet Region Languedoc Roussillon, France

Francesca Avolio Regional Healthcare Agency of Puglia, Italy

Cecilia Vera Universidad Politecnica de Madrid, Spain

Andrea Pavlickova NHS 24, Scotland, UK

Brian O’Connor European Connected Health Alliance

Fiona Lyne International Foundation for Integrated Care

Chair of B3 Action

Group

B3Co-ordination

Group

Action Areas Co-ordinators


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Figure 2. Action Areas of the B3 Action Group

3.4 Action Areas of the AG

9 Action Areas (AAs) were established within the B3 Group to deliver tangible deliverables and outcomes to enable tthe progress of the B3 Action Plan to be tracked.

The AAs were:

AA1 - Organisational Models

AA2 - Change Management

AA3 - Workforce Development

AA4 - Risk Stratifi cation

AA5 - Care Pathways

AA6 - Patient Empowerment

AA7 - ICT and Teleservices

AA8 - Finance and Funding

AA9 – Communication and Dissemination

The AA themes were based on the outcomes of B3 Delta Questionnaire (2012). B3 members identifi ed these areas as being the top challenges / priorities for the successful implementation of integrated care on a large scale in Europe.

Priority activities, deliverables and milestones of the individual AAs were chosen on two main criteria:

• The B3 Action Group considered the activities to be most likely to deliver the biggest impact on B3 targets;

• The members of the emerging B3 collaborative were committed to them and had resources which they could share to mutual benefi t.

1. Organistional models

2. Change management

3. Workforce development

4. Risk stratifi cation

5. Care pathways

6. Patient enpowerment

7. Electronic care records /ICT/ Teleservices

8. Finance and fundings

ACTION AREAS DELIVERABLES

Mapping of Innovative Practices

Implementation on large scale

Provide input and expertise through and open collaboration

Practical Toolkits

More integratd, more effi cient services

Commitments of the partners

ACTION GROUP WORK

LOCAL IMPLEMENTATION

6. Patient enpowerment

7. Electronic care records /ICT/ Teleservices

8. Finance and fundings

Provide input and expertise through and open collaboration

Commitments of the

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3.4.1 Action Area 1: Organisational Models

The objective of AA1 was to support European regions in expanding integrated care programmes to a wider population by:

a) Securing the support of policy makers for integrated care;

b) Improving integration between systems and levels – both vertical and horizontal;

c) Implementing new models of integrated care.

As such the activities of AA1 aimed to:

a) Map partnership models for implementation of chronic and integrated care programmes, including public-private partnerships, chronic disease management models, collaborative models for health and social care, care co-operatives and community partnerships;

b) Provide tools/practical tips for implementation and scale-up of integrated care;

c) Provide literature review/peer reviewed published evidence on analysis of integrated care.

3.4.2 Action Area 2: Change Management

The objective of AA2 was to support regions to influence public policy and resource allocation decisions within political, health, economic and social systems, and to provide more responsive care delivery.


a) Map best practice methodologies to support the implementation of chronic and integrated care, including funding models, effective use of incentives, engagement with stakeholders, implementation decision-support systems and co-production;

b) Provide analysis of barriers and successful approaches to implementation of chronic care programmes and integrated care models;

c) Provide model business cases to support implementation and scale-up of integrated care.

3.4.3 Action Area 3: Workforce Development

The objective of AA3 was to support European regions to:

a) Identify need for, and design, new roles with associated competence development planning;

b) Improve competences (related to integrated care) in management and leadership, clinical roles, health and social care workforce (including third sector);

c) Foster a culture of shared responsibility and joint working;

d) Provide training, information and knowledge transfer for patients/users;

e) Improve knowledge of formal and informal carers.


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a) Map reusable learning resources to support the delivery of awareness raising and education for all stakeholders, including the use of ICT education delivery methods and ICT decision support tools;

b) Provide workforce and training needs analysis;

c) Provide practical tools/practical tips for workforce development plans, system design to support best practice and design and implementation of ICT decision-support tools.

3.4.4 Action Area 4: Risk Stratification

The objective of AA4 was to:

a) Analyse the needs of patients/service users in the target groups for delivery of integrated care;

b) Support partners to implement risk stratification methodologies.

As such, the activities of AA4 aimed to:

a) Map existing patient stratification tools;

b) Identify in which European regions risk-based stratification has been used and document the approach developed and Delta achieved as a result;

c) Extrapolate the results of the above European regions to develop a European baseline with associated potential benefits resulting from adoption of risk stratification-based change at a delivery organisation, regional and European level;

d) Identify best-in-class patient stratification tools (with focus on disease severity/activity, co-morbidities, frailty and technological skills of users) to support

the objectives of European regions and delivery organisations involved in the EIP on AHA.

e) Provide tools/practical tips to help to identify patient clusters, embed targeted care plans, define a panel of indicators and apply the Integrated Care Framework to support patient centred management.

3.4.5 Action Area 5: Care Pathways


a) Align existing funded activities (EU, regional and local) and focus existing financial instruments to deliver chronic disease care pathways and integrated care programmes;

b) Develop the evidence base for integrated care pathways and associated guidelines and processes.


a) Map best practice implementation in the European regions, providing repository of implemented chronic care pathways, for chronic conditions and repository of multi-morbidity;

b) Define important questions on chronic repository diseases in old age adults;

c) Develop multisectoral care pathways for chronic respiratory diseases and their multimorbidities across the life cycle;

d) To embed the concept of frailty into chronic respiratory diseases;

e) To scale-up Airways-ICP in Europe and beyond;

f) To strengthen the WHO NCD Action Plan.

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3.4.6 Action Area 6: Workforce development

The objective of AA6 was to support patients/users to demand more responsive and integrated care programmes for chronic diseases.


a) Map coaching, education or approaches that help to improve patient adherence and compliance and support patient/user empowerment;

b) Provide tools/practical tips for roll out and scale up of patient/user empowerment initiatives;

c) Support patients/users’ access to clinical/care records and full participation in decision-making relevant to their own health/care management;

d) Support patient/user advocacy in the form of training and facilitating patient/user representatives to participate in policy development and decision-making processes;

e) Develop approaches to assessment and promotion of patients’ ability to understand and adhere to self-management plans, tailoring advice and support to the level of independence and health intelligence.

3.4.7 Action Area 7: ICT and Teleservices


a) Highlight the potential of ICT and teleservices to underpin the delivery of integrated care and to realise service efficiencies and cost-effectiveness and;

b) To improve the effectiveness of health and social care ICT systems and data sharing by identifying solutions which improve interoperability between record systems and data sharing.


a) Map existing ICT solutions focusing on how services for chronic disease management or integrated care are being supported by a common eHealth infrastructure including electronic care records, personal health records, decision-support systems and others.

b) Provide practical tools to support increased implementation of teleservices and other ICT solutions as part of integrated care programmes.

3.4.8 Action Area 8: Finance and Funding


a) Identify currently available finance and funding sources to facilitate shift towards integrated care;

b) Identify approaches to procurement to support adoption of integrated care by more European regions.


a) Map existing financial instruments, including European, national regional and private funding;

b) Provide tools/practical tips on how to access funds, who to call for help and how to write successful funding applications.


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3.4.9 Action Area 9: Communication and Dissemination


a) Ensure that the B3 Action Group functioned effectively and accountably for all B3 members;

b) Disseminate B3 activities and outputs to:

i. Encourage recruitement and retention of collaborative partners;

ii. Encourage regions and organisations in Europe to scale up the adoption of chronic care and integrated care programmes.


a) Set up and provide operational support to the B3 Action Group in the delivery of the B3 Action Plan.

b) Create and maximise opportunities to facilitate knowledge exchange within and outwith the B3 Action Group through the organisation of and participation in conferences, worshops, webinars, publications and co-ordinated campaigns to raise awareness of the activities and deliverables of the B3 AAs.

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4. Activities & Achievements

4.1 General Results

Local implementation is both the foundation and aspiration of the work of the B3 Action Group. B3 members are implementing chronic disease management programmes in 44 regions; they are now beginning to focus on the scaling up and replication of their practices to reach the target of 50 regions, and cover 10% of the target population.

The expertise of the B3 Action Group is reflected in a rich collection of over 100 good practices as well as set of other resources, collected throughout 2013-2015.

The members have worked together to develop practical tools that support service local service delivery:

• Maturity models focusing on three key areas: organisational models, change management and the development and adoption of eHealth programmes and teleservices to support integrated care and service innovation, were developed. These models were subsequently converged into one comprehensive model - the B3 Maturity Model. This model covers a broad range of areas relevant for implementing integrated care and functions as a self-assessment tool that provides objective measurement and guides regions how to improve their capacity to deploy services.

• Validated medical guidelines in respiratory diseases have been developed, through collaboration of hundreds of health professionals, public authorities and patient organisations, into an integrated care pathway for respiratory diseases, with

• the goal of replicating it in their own countries.

• Experts collected and analysed tools for risk stratification of the population for optimised and targeted care, and make these available for organisations that are planning to develop or improve their systems.

• Citizen empowerment framework helped to develop common understanding and shared vision for integrated health and social care services that centres on the patients and their communities.

The B3 Action Group has been working in close collaboration with a number of EU funded projects, to provide input and support to the dissemination of the deliverables. The examples of such projects include SmartCare, Beyond Silos, Care Well, ASSEHS, ACT, Momentum, Project Integrate and others. There is also a continuous channel of communication with the EU Joint Action on Chronic Diseases and promoting healthy ageing across the life-cycle. As a results of these joint collaborations, the B3 members and wider EIP on AHA community benefit from additional evidence and tools supporting large scale deployment in Europe, including:

• Momentum Blueprint and its 18 critical success factors for scaling-up technology enabled care in general and telehealth and telecare services in particular.

• ACT Cookbook on best practices for large scale coordinated care and telehealth deployment in Europe.

• ASSEHS Appraisal Standard a consolidated standard for appraising to stratification techniques facilitating critical and comprehensive comparison among different risk stratification models deployed in European regions.


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The B3 Action Group has also stimulated inter-regional cooperation formalised in the form of Memoranda of Understanding for example between Scotland and Basque country as well as development of regional networks for active and healthy ageing in Greece, Puglia and Languedoc-Roussillon regions.

The B3 Action Group has been working laterally and collaboratively. Examples of this approach are the joint work on innovative procurement and interoperability together with the Action Group C2 on Interoperable Independent Living Solutions, as well as the initiative to find synergies across the six Action Group on patient empowerment.

Action Group members have organised and presented at a series of high-level European and regional conferences and workshops and participated in professional exchanges to promote integrated care on health agenda.

In addition, the B3 Action Group organised two webinars on Change Management and B3 Maturity Model. Action Groups members have also produced three articles on change management, one article on the B3 Maturity Model and 22 articles on integrated care pathways were published.

In addition, by providing evidence and inspiration for policy-making the Group has contributed to ensuring that integrated care is on the European agenda as one of the most promising solutions to assure the sustainability of the systems for health and social care.

4.2 Achievements of the collaborative work

The joint activities of the B3 Action Group throughout 2012-2015 resulted in the B3 Toolkit for Replication and Scaling-Up Integrated Care in Europe.

Figure 3. B3 Toolkit Framework

Framework for B3 Integrated Care Toolkit

B3 MATURITY MATRIX

REPOSITORY

B3 ASSETS

Tools

Methodologies

Review docs

Papers

EU-funded projects

Tailored recommendations

Knowledge Transfer

Relevant Good Practices

from other regions

ObjectiveSelf-assesmentTool for Regions

Identificationof Gaps

Benchmarking of EIP B3 Regions

B3 GOOD PRACTICES

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The Toolkit is intended to assist European regions in their journey towards integrated care by providing practical tools, recommendations and guidelines on how to implement and replicate integrated care in Europe. The Toolkit also serves as repository of good practices and evidence collected for integrated care.

The B3 Toolkit consists of three strands:

1. B3 Assets

B3 Assets are concrete outcomes of individual Action Areas, addressing specific challenges of integrated care. The Assets include literature reviews, methodologies, guidelines, recommendations, tools, scientific articles and other resources from EU funded projects relevant for the B3 Action Group.

The following Assets are included in the B3 toolkit:

• Literature review on Organisational Models is a review and analysis of current conceptual models in integrated care, including the identification of barriers and facilitators for the implementation of integrated care.

• Organisational Model Framework provides grouping of various aspects and levels of integration, including the positioning of 7 European regions.

• Maturity Map for Change Management provides the overview of key dimensions for change management based on the survey undertaken in 12 European countries.

• Briefing Note on Workforce Development provides the outcomes of mapping exercise on state of play on workforce development in Europe.

• A European Risk Stratification Baseline, which includes the Methodology,

Database and Analysis of most relevant Publications on the subject, with information on available strategies, models and tools used for risk stratification in health services. It is the result of a desktop search that retrieved 59 documents and a scoping review that collected 89 documents. 54 documents are classified as design and definition of the tool; 58 documents are classified as feasibility of implementation of the risk stratification tool and finally, 36 documents are identified as impact of the risk stratification in health services.

• Description of the Risk Stratification Tools, with an Overview of Selected Tools deployed in Europe.

• Risk Stratification Tools Analysis Methods like OPIMEC survey (www.opimec.org) that aims to collect features of the relevant risk tools in Europe.

• Airways-ICP care pathways, a design for integrated care pathways for respiratory diseases, which have been launched in 26 countries and globally via WHO, linked to Scaling-up Strategy.

• Patient Empowerment Framework is consensus-based framework of the dimensions to be considered in the patient empowerment, including pre-requisites, processes, tools and anticipated patient outcomes.

• Case Studies on Patient Empowerment that illustrate success factors and barriers for rolling-out and scaling-up patient empowerment processes.

• ICT Service Matrix is a reference document that characterises the different types of services in an integrated health and care information infrastructure.


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2. B3 Maturity Model

The B3 Maturity Model is a self-assessment tool to address the readiness of regions/organisations to adopt integrated care (Annex 1).

Why do we need B3 Maturity Model?

Integrated care in Europe is being adopted at different rates and in diverse ways across regions of Europe. To support scale up and deployment of integrated care in line with the European scaling-up strategy, one needs to understand:

• What actions have the more progressive regions taken in order to be successful?

• What can we learn from these pioneers to overcome barriers and accelerate results?

• How can lessons learned help other aspiring regions to speed up their own adoption?

What is the B3 Maturity Model for?

• To assess a health and care system’s capacity to adopt integrated approaches to deal with challenges of ageing.

• To identify possible gaps and areas that need attention in a health and care system.

• To provide recommendations and methodology on how to improve.

• To position the European regions in terms of their weakness and strengths in integrated care.

• To provide an opportunities for sharing good practices and learning from each other - “matchmaking”.

How to use B3 Maturity Model

The Maturity Model is a conceptual model intended to assess a health and care system’s capacity to adopt integrated care approaches to deal with challenges of ageing. The Maturity Model has been derived from interviews with 12 European countries, or regions within a country, responsible for healthcare delivery that are also members of the B3 Action Group on Integrated Care. The many activities that need to be managed in order to deliver integrated care have been grouped into 12 ‘dimensions’, each of which addresses a part of the overall effort. By considering each dimension, assessing the current situation, and allocating a measure of maturity within that domain (on a 0-5 scale), it is possible for a country or region to develop a ‘radar diagram’ which reveals areas of strength, and also gaps in capability. Using these insights, and comparing the radar diagram with those of other regions/countries that have conducted the same exercise, it should be possible to find expertise to fill the gaps in capability, and to offer to others knowledge and experience from the sites’ areas of strength.

3. B3 Good Practices

The compilation of good practices is the product of the unique collaborative work of the members of the B3 Integrated Care Action Group. In this collective effort, the experts of the Action Group were polling their knowledge and experience to map existing initiatives relevant to the delivery of integrated health and social care.

This mapping exercise was undertaken to give a picture of the on-going efforts towards implementing innovative solutions in the field of active and healthy ageing; it was not meant to select or validate a limited number of practices. This inclusiveness reflects the collaborative work and knowledge transfer of the EIP on AHA.

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Over 100 good practices were collected throughout 2013-2014 demonstrating that for the management of chronic diseases and for the provision of comprehensive, long term care for the older people, integrated care practices have the potential to improve the quality and sustainability of services. From the good practices and the expertise of the B3 Action Group, the following key messages emerged:

• Good practices have shown the development of new Organisational Models with broad partnerships involving patients, users, healthcare professionals, carers and payers, decision-makers and other stakeholders that can support a more responsive and integrated care programme for chronic diseases.

• Implementing Change Management can be done through incentivisation and advocacy methods, processes, tools and techniques for reducing and managing people’s resistance to change when implementing organisational transformations.

• Good practices related to Workforce Development, Education and Training offer replicable training programmes, and show how a skilled healthcare workforce can answer to the challenges of increased and changing demand.

• Risk Stratification optimises the delivery of integrated care by analysing the needs of patients/users in the target groups to predict risks and tailor services to the needs of the patients.

• The work on Care Pathway Implementation builds on existing guidelines to develop multi-sectoral integrated care pathways (ICPs) for replication. ICPs are structured multi-disciplinary care plans, which deal essential steps in the care of patients with a specific clinical problem.

• Patient/user empowerment, health education and health promotion activities are ubiquitous. The good practices demonstrate different ways which ensure that the services are centred on the patient/users, who are active and involved partners in the management of their diseases.

• There is a growing range of Electronic Care Records, ICT and Teleservices; some are closely engaged with the delivery of health and social care services to meet the needs of patients and those in need of care; others aid the governance, coordination and audit of care.

• Finance and Funding are crucial to provide incentive to the transformation and for the sustainability of service deployment. Ecosystems created around health and care services can contribute to growth and job creation.

4.3 Key messages and lessons learned

Key messages of the B3 Action Group:

• Integrated care in Europe has been implemented in diverse ways and at different pace; there is “no size fit all” solution and response to the challenge of ageing population;

• There is evidence that integrated care practices have the potential to improve the quality and sustainability of health and care services;

• The catalogue of B3 good practices has contributed significantly to a better understanding of the existing solutions, resources and expertise that can be pooled towards the shared goals of the EIP on AHA;


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• The good practices are often limited to a particular pilot or region but achieving the ambitions of the EIP on AHA requires scaling-up of the local innovative solutions across Europe.

• The good practices and systems are shaped by the context, and therefore, features of the intervention need to “fit” into context appropriately.

• The challenge remains how to best leverage the existing body of evidence and make the learning embedded in the good practices readily accessible to potential adopters in Europe.

• The B3 Toolkit intends to address the challenge of scaling-up in Europe by providing evidence on successful

• Implementation of integrated care solutions and tools to stimulate innovation and changes in health and social care systems in Europe.

Lessons learned

• The activities of the B3 Action Group need to closely align with the strategic priorities of the B3 members.

• The level of resources and commitment required to successfully complete collaborative work within the EIP on AHA Action Groups should not be underestimated.

• Short-term activities secure more effective engagement and involvement of B3 members.

• Engagement and active involvement of B3 members varies over a period of time, according to capacity of members.

• Added value and return on investment, incentives to actively contribute to the activities of B3 Action Group need to be evident.

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5. Conclusions and Future Activities

The activities organised and implemented by the B3 Action Group have contributed to the overall aims of the EIP on AHA by:

• Providing evidence and sharing good practices on implementation and deployment of integrated care and chronic disease management programmes, including remote monitoring in Europe;

• Providing supportive tools to help European regions on their journey to integrated care and reaching the implementation of innovative solutions in active and healthy ageing at large scale;

• Pooling resources and expertise on integrated care towards shared objectives and vision of the B3 Action Group which is to replicate and tutor integrated care for chronic diseases in Europe;

• Knowledge sharing about the delivery of services for chronic conditions management in an integrated way addressing range of challenges such as incentives schemes, workforce education and training, patient empowerment, change management ICT solutions, care pathways, risk stratification and models for organisation of health and social care;

• Building partnerships for current and future collaboration in the area of active and healthy ageing and integrated care specifically to unlock the potential of innovation in the transformation of healthcare systems in Europe.


November 2015

6. AnnexesAnnex 1: Dimensions of the Maturity Model for Integrated Care

Capacity Building

Readiness to Change

Structure & Governance

Information & eHealth Services

Standardisation & Simplification

Finance & Funding

Removal of Barriers

Population Approach

Citizen Empowerment

Evaluation Methods

Breadth of Ambition

Innovation Management

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November 2015


Organisation Country

Agencia Valenciana de Salud Spain

Agenzia sanitaria e sociale regionale Italy

Andalusian School of Public Health Spain

Assembly of European Regions (AER) France

Católica Porto Portugal

Centre for Health and Technology, University of Oulu Finland

COCIR Belgium

Coöperatie Slimmer Leven 2020 Netherlands

CORAL United Kingdom

CSI-Piemonte (Consortium for Information Systems) Italy

Departament De Salut – Generalitat De Catalunya Spain

Departamento de Salud Valencia-La Fe Spain

Department of Health and Consumer Affairs of the Basque Government Spain

Department of Health, Social Services and Public Safety United Kingdom

Dutch Associated Health Insurance Companies Netherlands

e-Health Unit, “Sotiria” Hospital, 1st RHA of Attica Greece

EHTELg Belgium

EUREGHA United Kingdom

Europäische Vereinigung für Vitalität und Aktives Altern eVAA e.V. Germany

European Centre for Social Welfare Policy and Research Austria

European Connected Health Alliance (ECHAlliance) United Kingdom

European Federation of IASP® Chapters (EFIC®) Belgium

European Federation of Nurses Associations. Belgium

European Platform for Patients’ Organisations, Science and Industry Belgium

European Wound Management Association (EWMA) Denmark

Federico II University Italy

Fondazione Bruno Kessler (FBK) Italy

Fondazione Democenter-Sipe Italy

Hospital Clinic - IDIBAPS Spain

IESE Business School Spain

IK4 Research Alliance Spain

Institute of Health Carlos III Spain

IRCCS, Salvatore Maugeri Foundatio Italy

Landstinget Sörmland Sweden

Life Supporting Technologies – Universidad Politecnica de Madrid Spain

Medical Delta Netherlands

Medical University of Warsaw - Department of Prevention of Environmental Hazards and Allergology Poland

Municipality of Palaio Faliro Greece

Mútua Terrassa Spain

New Tools for Health Sweden

NHS Yorkshire and the Humber United Kingdom

NHSScotland, co-ordinated by NHS 24 United Kingdom

Novartis Switzerland

Operational Research Centre – Universidad Miguel Hernández de Elche Spain

Annex 2: Overview of the B3 commitments


November 2015


Philips Healthcare Germany

Radboud University Nijmegen Medical Centre Netherlands

Région Languedoc Roussillon France

Region North Denmark Denmark

Region Syddanmark (Region of Southern Denmark) Denmark

Regional Healthcare Agency of Puglia Italy

Sermas-Hospital Universitario De Getafe Spain

Servicios de Teleasistencia S.A. (ST) Spain

Spanish Collaborating Centre of the Joanna Briggs Institute (Nursing and Healthcare Research Unit) Spain

University of Alicante Spain

University of Valencia (UVEG) Spain

Zealand Denmark Denmark

Adiper Servicios Sociosanitarios Spain

Agenzia Sanitaria Regionale – ARSan Italy

Andalusian School of Public Health Spain

APDP - Portuguese Diabetes Association Portugal

ARESS Piemonte - Regional Agency for Healthcare Services Italy

Arsenàl.IT - Veneto’s Research Centre for eHealth Innovation Italy

ASL Roma A Italy

Asociación Bio-Med Aragón (Bma) Spain

Aura Andalucia, S.L. Spain

Campania Region Health Care Authority Italy

Catalan Health Institute Spain

CCTR Netherlands

Centre of eHealth and Health Care Technology Norway

Consejería de Sanidad y Política Social, Región de Murcia, España/Department of Health and Social Po Spain

Consejería de Sanidad y Servicios Sociales de la Comunidad Autónoma de Cantabria Spain

Consiglio Nazionale delle Ricerche, Istituto Tecnologie Biomediche, e-health Unit Italy

Consorci de Salut i Social de Catalunya Spain

Coventry University, Health Design Technology INstitute United Kingdom

Culminatum Innovation Oy LtD Finland

Dip. Scienze Cardiovascolari, Resp., Nefr., Anest. e Ger ‘Sapienza’ University of Rome Italy

EMONICUM Institute Slovenia

EPSO (European PEPSO (European Partnership for Supervisory Organisations in Health Services and SC) Netherlands

Eurobiomed France

European Forum for Primary Care Netherlands

European Health Forum Gastein (EHFG) Austria

European Health Futures Forum United Kingdom

European Health Management Association Belgium

Everis Slu Spain

Everis Spain S.L.U Spain

Filha (Finnish Lung Health Association) Finland

Fundació Privada Parc de Salut de Sabadell (Short name: Parc de Salut) Spain

GARD Turkey Turkey

Greater Stavanger Economic Development AS Norway

i2CAT Foundation Spain

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November 2015



IBM UK Limited United Kingdom

International Foundation for Integrated Care United Kingdom

Istituto di Ricerche Farmacologiche Mario Negri Italy

Italian Society of High Blood Pressure/School of Medicine University of Salerno Italy

Klinisk Informatik Denmark

Liverpool Community Health NHS Trust United Kingdom

Lombardy Technological Cluster “Technologies For Life Environments” Italy

Lovexair Foundation Spain

LUISS Guido Carli Italy

Maccabi Institute for Health Services Resear Israel

Medical University of Warsaw Poland

Medicon Village Sweden

Ministry of Social Affairs of Baden-Württemberg Germany

Older People’s Commissioner for Wales United Kingdom

Osakidetza.Hospital Galdakao-Usansolo Spain

Portuguese Directorate General of Health Portugal

Région Languedoc Roussillon France

Region Skåne/Skåne County Council Sweden

Regione Lombardia Italy

Sanofi Italy

Senior Europa SL, comercial name Kveloce I+D+i Spain

Telemedico S.r.l. Italy

TNO Netherlands

to asl3 regione piemonte italy Italy

Universidade do Porto Portugal

Universita’ Cattolica Del Sacro Cuore Italy

University of Coimbra Portugal

University of Copenhagen Denmark

University of Oslo Norway

University of Sannio Italy

University of the Highlands and Islands United Kingdom

Univerza v Mariboru Slovenia

Vall d’Hebron Institute of Research Spain

Gertner Institute Israel

University of Deusto Spain

Barcelona Digital Technology Centre Spain

European Social Network United Kingdom

Syreon Research Institute Hungary

Belfast Metropolitan College UK

Biomedical Simulation and Imaging Laboratory (BIOSIM), National Technical University of Athens (NTUA) Greece

AOK Rheinland/Hamburg Die Gesundheitskasse Germany

Hospital Clínic Barcelona Spain

Institute of Computer Science, Foundation for Research & Technology-Hellas (FORTH) Greece

Health Region Cologne Bonn Germany

Kent County Council UK

South East Europe Healthcare Greece

SoMoMed Ltd t/a Assesspatients Ireland

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STATE OF PLAY OF ACTION GROUP B3 · 2015-12-21 · B3 Action Group on Replicating and Tutoring Integrated Care for Chronic 7 Diseases, Including Remote Monitoring at Regional Level