Meeting in Trieste for the final Conference of the 3-year EU project, aiming at joining up ICT and service processes for quality integrated care in Europe, the Smartcare partners were presented the project outcomes, namely: the results of the evaluation of the SmartCare services, piloted in nine European regions; the lessons learned by the people developing, implementing and operating the frontline; the socio-economic and business aspects of up-scaling integrated care; and the project guidelines for the implementation of integrated e-care services. EFN has contributed to these deliverables by making sure the chronic care model and case management are taken up in the users’ recommendation.
One of the major challenges faced in the delivery of health and social care in Europe is the increase in the number of people living with chronic conditions – result of the global population ageing. As the citizens of Europe grow older, they live longer with their conditions and require on-going access and support for health and social services. At EU level, the introduction of eHealth services is facilitating this access to healthcare, whatever the geographical location, or innovative tele-health and personal health systems. Furthermore, through eHealth it is possible to shift the focus towards person-centred care, enhance patient empowerment, and to ensure continuity of care across primary and secondary health and social care sectors. In this process, EU guidelines are a first step forward. These guidelines, building on existing good practices across the European regions, relate to Prevention, Clinical Practice, Advanced Roles, Integrated Care, and ePrescribing, and make clear that nurses and social workers, with the right knowledge and skills, will add considerable value and form an important link between technological innovation, health promotion and disease prevention (ref.: EFN EU project ENS4Care).
Also, integrated care as a way to ensuring optimal health and social outcomes being achieved for all people living in the EU, and in special regional development of integrated care, is key. In many EU countries integrated care is at its very early stage of development as bringing care closer to citizens is not yet perceived as contributing to the sustainability of health and social systems. However, national legislation should follow in merging health and social care, including their budgets. A good example is Finland (Eksote, South Karelia), where particular attention is given to enhancing the remaining resources of the elderly and supporting independent living. A nurse lead process, which also plays an important role in SmartCare project, is the service need assessment, aiming to analyse and determine a person´s needs for care and various services, and ensuring that the person receives the right care and service in a timely manner. Service needs assessment is done as the first step in every contact between a patient/customer and nurses in advanced roles available 24/7, 365 days, to make sure this continuity is guaranteed. The primary objective in elderly care is to allow the elderly persons to live in their homes as long as possible.
Finally, we can say that for the past decade the European Institutions, and the European Commission in particular, have been championing a range of initiatives and making steady steps towards improving the quality, safety and efficiency of health service delivery in Europe; however, success has been variable. But a renewed focus on delivering health and social care in the community implies an appropriately designed frontline community, as the nursing workforce, at the interface of health and social care services. This is instrumental in co-ordinating care pathways and promoting a healthier population that is empowered and fully engaged in policy decision making. The EU needs to engage more frontline, its citizens.