Challenge

Frail older people with severe chronic conditions often require support from hospitals, primary care, social services and informal caregivers. When these services operate separately, information may be duplicated or missed, treatment becomes harder to coordinate and patients face a greater risk of emergency visits, hospitalisation or admission to residential care.

Solutions

CareWell implemented two ICT-supported pathways: integrated care coordination and patient empowerment and home support. Shared digital platforms helped professionals exchange information, coordinate scheduled emergency care, monitor patients at home and avoid duplicated diagnostic, treatment and rehabilitation activities. The services also supported treatment adherence, self-management and the involvement of informal caregivers. The platforms used open standards and interoperable technologies where possible, with information sharing governed by national and European privacy and consent requirements.

Results

CareWell piloted its integrated-care model in six European regions. An evaluation involving 856 patients aged 65 or older found that participants receiving CareWell services made significantly fewer emergency -room visits and had more contact with general practitioners and primary-care nurses than patients receiving usual care. The project demonstrated how ICT-supported integration could strengthen the role of primary care, improve coordination across organisational boundaries and help older people manage complex conditions at home. It also produced care models, pathways, service specifications, an evaluation framework, and ethics and data-protection guidance to support wider implementation.