Multi-level integration for patients with complex needs






European Commission (EC)



CareWell will enable the delivery of integrated healthcare to frail elderly patients in a pilot setting through comprehensive multidisciplinary and tightly knit programmes. ICTs will play a major role in the coordination and communication of healthcare professionals and of patient centred delivery of care at home. CareWell will predominantly focus on the provision of care and support to older people who have complex health and social care needs, 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 will be achieved through ICT enabled health and social care services coordination, monitoring, patients self-management and informal care givers involvement. The ICT platforms and communication channels will avoid duplication of effort when dealing with patients’ diagnostic, therapeutic, rehabilitation or monitoring and support needs. Additionally, ICT-based platforms can improve treatment compliance, enhance self-care and self management and increase patient and carer awareness on their health status. All of which will improve clinical outcomes and enable people to lead fulfilled lives. Moreover technologies will support the patients’ informal caregivers highlighting when respite care or additional professional input is required.

The two CareWell services are based on (1) integrated care coordination and (2) patient empowerment & home support pathways supported by ICT. These care pathways will cut across organisational boundaries. They will activate the most appropriate resources healthcare and social care services available, both for scheduled and unscheduled care. Information sharing will need to comply with European and national regulations relating to consent and privacy. The ICT platform will be based, whenever possible, on open standards and multi-vendor interoperability and collaboration among ICT suppliers will be strongly encouraged.