Objectives

Work package 4 considers how the health systems in the three pilot site countries, the clinical teams and other professionals working in the hospitals and general practices involved, will need to work differently when using C3-Cloud solutions. It has examined how care for patients with multi-morbidity is carried out today, so it can work out the changes that each site will need to make in order to deliver better, more integrated and more patient empowered care. It will eventually publish recommendations for other health systems wishing to adopt the C3-Cloud solutions, so that they can do so smoothly and make best use of C3-Cloud technology. 

Achievements to date

  • Guidance on how individual clinical guidelines can be reconciled for the automation of personalised care plan development.
  • Development of new organizational models for improved delivery of integrated care.
  • Guidelines for Management of Changes in the Models of Care Delivery, taking into account diversity of European national and regional systems.

Organizational and care model analysis for C3-cloud deployment preparation

Current status

 Exploration of New Patient Pathways and Corresponding Care Plans

  • Explore new patient-centred pathways and the corresponding personalised care plans.
  • Interlink the clinical guideline definitions
  • Revision of the patient pathways and personalized care plans after the experience from operation in real-life settings.
  • Update the guidance deliverable following pilot deployment

 Development of New Organisational Models for Improved Delivery of Integrated Care

  • Analysis and comparison of the existing organisational models for integrated care in Europe and the rest of the World.
  • Propose of organisational model changes that supports interactions of multidisciplinary teams and patient empowerment.
  • The resulting new organisational models will be practiced in proof-of-concept prototypes in the three pilot regions

  Change Management for New Ways of Care Delivery

  • Examine the implications for health care provider organisations and larger-scale delivery entities.
  • Establishment of a cross stakeholder advisory group to examine the implications for scaling up adoption.
  • Revision of the guidelines proposed, after the experience from operation in real-life settings.

Intended outcomes

Guidance for and development of new patient pathways and corresponding personalised care plans that can perform multi-morbid chronic disease management taking into account functional, social and psychosocial aspects, different professional perspectives and experience

Development of adaptive organisational models for improved delivery of patient-centred integrated care that address the challenges posed by varying contexts

Development of guidelines for smooth management of changes in models of care delivery, which are identified necessary for integrated care services

Deliverables

D4.1 Guidance for the Development of New Patient Pathways and Corresponding Care Plans public
D4.2 New Organisational Models for Improved Delivery of Integrated Care public
• D4.3 Updated Guidance for the Development of New Patient Pathways and Corresponding Care Plans public
• D4.4 Guidelines for Management of Changes in the Models of Care Delivery public

Those marked with a public will be publicly available after approval.