Challenge

Older people with chronic conditions often receive help from hospitals, doctors, community nurses, social workers and family members.  Although these groups provide vital care, they mostly use separate records and communication systems, meaning important information is not always available to everyone involved. This could interrupt care after hospital discharge and make long-term support at home more difficult to coordinate.

Solutions

BeyondSilos implemented ICT-supported integrated care across seven European regions. Shared records, home-monitorning technologies and workflow tools connected healthcare, social care, self-cate and informal support. Two common pathways were adapted locally: short-term home support following an acute event and long-term support for people with complex needs. The pilots built on experience from the SmartCare project and used the MAST evaluation framework and ASSIST cost-benefit methodology.

empirica contributed to the requirements analysis, care-pathway development, socioeconomic impact assessment, usiness-case modelling, communication and dissemination.

Results

More than 10,000 people benefited directly or indirectly from the services. The formal evaluation included 973 older care recipients with an average age of 82, alongside healthcare professionals, social care staff and more than 541 informal carers. Professionals reported improved care integration, while participants felt safer, better supported and more in control of their conditions.

The services were found to be safe, and most pilots achieved a positive socioeconomic return, with overall benefits exceeding their costs. However, the evaluation found no significant reduction in hospital admissions or clear improvement in functional ability or depression symptoms, demonstrating the need for further research into outcomes for frail older population.