Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing

Integrated care for frail elderly patients in the Basque Country ‐ Carewell project

CareWell project has focused on the provision of care and support to older people who have complex health and social care needs. They are at high risk of hospital or care home admission, and require a range of high‐level interventions due to their frailty and multiple chronic diseases. This has been achieved through ICT enabled healthcare services coordination and monitoring, patients' self‐management, and informal care givers' involvement.
This use case focuses on the results from the pilot in Osakidetza (Basque Country). Patients were above 65 years‐old and had at least two chronic diseases among Diabetes Mellitus (DM), Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD).
The intervention consisted on the one hand of new professional roles and the use of ICT to support communication among the different stakeholders and on the other one on patient empowerment.