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For more than three years, 23 regions and a total of 42 partners have worked towards making ICT-supported integrated care a reality. Launched in March 2013, in Trieste (Italy), this project funded under the Information and Communication Technologies Policy Support Programme (ICT-PSP 2012) aiming at joining up the Information and Communications Technologies (ICT) and service processes for quality integrated care in Europe came to an end in August 2016. The objective of SmartCare was to enable the delivery of integrated care to older European citizens to support them to live independent lives within the community by providing the ICT tools necessary to integrated care pathways between social and health services, as common access to home platforms, monitoring physical parameters, environmental and behavioural monitoring, as daily schedulers, medication management, falls prevention, exercises for cognitive faculties and coaching.

As partner in this project, namely in WP1 (Requirements and integrated care pathway development), WP2 (Service Process Model), WP3 (Integration infrastructure Architecture and Service Specification), WP8 (Pilot evaluation), WP9 (Exploitation support and dissemination) and WP10 (Project management and performance monitoring), and working with EFN members from the 35 EU Member States to encourage further uptake at national level, the EFN was also member of the Users Advisory Board (UAB) whose task was to make sure that the interests and needs of all users (elderly, patients, informal carers, nurses, other healthcare and social professionals involved in care and ICT) were properly taken into account during and after the project.

SmartCare built up on existing ICT services in all pilot regions supporting the delivery of care and already to some extend adapted to meeting the pressing need for coordination across care-givers. Existing platforms were adapted in the direction of supporting coordination of the entire spectrum of care services offered to older people  to improve their quality of life and extend their independent living in a way which remains financially sustainable in view of the evolution of demographic indices and restrictions in public spending.

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.

The following regions made up the 1st wave of SmartCare pilots: Friuli-Venezia Giulia, Scotland, Aragon, and Southern Denmark, followed by a 2nd wave: Tallinn, South Karelia, Attica, North Brabant, Kraljevo and Uppsala.

The EFN worked with its members from 35 EU Member States (representing 6 million nurses throughout the European Union and Europe) on disseminating and using the outcomes within the national health systems. Furthermore, the EFN’s 35 knowledge brokers encouraged further uptake at national level, with the ultimate goal to mainstreaming the project results, as through EFN connections, the wide availability and adoption of the results. The evidence gathered on improved economy, efficiency of health services by using chronic conditions management, improved satisfaction and health outcomes were translated to those responsible for eHealth policy in Europe and at national level through the EFN membership.

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