Telemonitoring focused on multi-chronic patients: provisioning of integrated care
About this good practice
More than 10 years of piloting in different settings has helped to define which service models to provide for each of the patient’s needs, independent or dependent.
This practice provides integrated care to complex chronic patients taking into account their health needs and expectations via a collaborative platform with an ICT telemonitoring solution and preventive monitoring of vital signs. Specifically, it aims to maintain the highest possible degree of personal autonomy & patient integration in their entourage & society. Its aim is to contain costs & optimize resources for the sustainability of the health & social systems and provide higher quality of the care in a coordinated way.
It has proved useful in the rural areas, avoiding patient travel to hospital/healthcare centre. In the event of any deviation in his/her parameters, healthcare personnel are mobilised to care for the patient. Thus relieving of healthcare system workload by identifying early decompensations. Moreover, it promotes longer independent living of chronic patients. And finally supports the public healthcare system to be proactive instead of reactive, in addition to enhancing care & life quality, sustainability of the public healthcare system & to allow equity access to all services by all citizens.
Today it is a consolidated service. Such is the case, that Aragón co-leads the Spanish Ministry of Health Telemonitoring Project to be implemented in all of Spain, from 2024-2026.
Resources needed
Material/equipment resources: integrated care platform, telemonitoring platform, monitoring devices, servers
HHRR: nurses, doctors, social workers, carers, family, peer volunteers
Entities: day care centres, Red Cross, nursery homes, elderly social centres, patient associations
Evidence of success
Greater satisfaction from professionals, patients and carers.
Call centre dimension: Automatic alarms permit to size up the call centre and its activity timeframe. 1100 chronic patients will consume 4h approx. of staff of call centre/day.
Enhancement in quality of life of patients, and reduction in anxiety and depression.
Clinical activity: Frequentation shift from specialised care to primary care and from emergencies to programmed activity. Healthcare activity shift from reactive to proactive.
Potential for learning or transfer
Although older adults >50 have a higher risk of chronic pathologies, decrease in mental capacities, mobility and a greater risk of poverty and social isolation, they are however a valuable resource in contributing to society and living actively while generating new jobs and growth.
Introduction of eHealth, telecare, integrated care, independent living is proving to increase efficiency of health and long-term care systems at regional and national level, and thus leading to cost savings and enhancing accessibility to healthcare and social services in rural and remote areas.
The best practice where implemented has shown to enhance healthcare delivery, settle population, improve lives of the elderly, strengthen services at community level (municipalities, associations, social services, community nursing, etc.)
Overall, the Telemonitoring best practice in Aragón is tried-and-true-demonstrable and easily replicable in other regions of Europe.
