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Clinical Continuity by Integrated Care (Homecare)
Start date: Apr 1, 2009, End date: Mar 31, 2012 PROJECT  FINISHED 

Our comprehensive approach to clinical continuity by integrated care (IC) across the secondary-primary interface departs from a preliminary literature review selecting frequent chronic conditions (CC) as stroke, COPD and HF as our focus areas. However, within each of these areas IC is a small activity, still, requiring more basic research. As IC for these different CC are based on the same patient values (feeling safe, participation and primary feedback) the synergistic effect from cross-sectional relationships arising from this project should be significant. In all, our 11 deliverables may be important to trespass the critical mass required for an expansion of this kind of IC as far as justified by the empirical results.In general, moderately improved health at minimal costs might be expected from some point of their life to a large segment of the population in EU suffering from the CC in study. That would deliver goodwill to the EU! Special projects are going to investigate the relevance of the access to health improvements by these Low-Tech-IC-interventions in low- and middle-income MS with distinct problems of fragmented care systems.The project has several milestones:1) A kick-off Symposium aiming to establish a common decision-making framework introducing the HTA method2) A systematic literature review checking preliminary choices of focus areas after 6 months3) After 18 months a comprehensive status of the progress of the different trials and surveys is scheduled with respect to both timeliness and scientific content4) After 30 months the practical IC-guides for clinicians on stroke, heart failure and COPD, respectively, should be concluded after an extensive hearing in an international network related to the 2nd Annual meeting of the consortium.5) After 36 months the final reporting and dissemination of an HTA of IC should provide the top level of clinical, administrative and political decision-makers with a solid base for progressive decision-making.In conclusion, a meso-strategy for dissemination of IC in EU with formation of a country-specific, multidisciplinary network of specialists in the involved fields as corner-stone for setting up new clinical implementations and recommendations for adaptation of financial and organisation conditions.
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