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Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community dwelling persons of EU Countries [SUNFRAIL] [664291] - Project
Project abstract

General Objective The proposal is promoted by a network of EIP-AHA Italian Reference Sites with the intent to validate and standardize approaches on frailty and multimorbidity by building on the instruments developed with the European Commission Innovation Partnership on Active and Healthy Ageing. Key-partners of the project are mainly EIP-AHA Reference Sites (and AG Coordinators: A1, A3, B3), representing countries from the northern, southern and eastern part of Europe. Methods and Means Proposed actions will support the development, validation and experimentation of a model to improve the detection, prevention and care of frailty and management of multimorbidity in EU countries, providing partners with different approaches to care from which to adopt/adapt their own systems/services. The model will be experimented in selected RS. It will support the development of innovative tools for the prediction of frailty and multimorbidity by level of care, focussing on community based prevention and avoidable hospitalization. It will offer the EC and the MS with instruments for the potential replication of the model/good practices through the EIP-AHA initiative. The involvement of European networks (EUREGHA), and of the International Scientific Research Networks in the field of frailty and disability (IAGG-GARN), will grant necessary scientific support and advocacy for a real EU and international value.Project’s Main Outcomes• A shared model of references on frailty and multimorbidity.• A tool kit for the prediction of frailty and multimorbidity by level of care: Primary care: easy to use tool to assess risks of frailty through the physical function (slow gait speed, others); tools to support the design of information systems and care pathways for the management of chronic diseases. Secondary-tertiary level: identification of methods and instruments to predict multimorbidity. Other tools: instruments for professional’s skills improvement and analysis of costs.

Summary of context, overal objectives, strategic, relevance and contribution of the action

Sunfrail was a 30 - months European project funded by the EU Health Programme 2014-2020. The consortium, coordinated by Emilia-Romagna Region, brings together 11 partners of the European Commission Innovation Partnership on Active and Healthy Ageing from 6 EU Member States of the northern, southern and eastern part of Europe.

The project’s main objective was to develop and experiment a model, good practices and tools to improve the identification, prevention and care of frailty and management of multimorbidity in community dwelling persons (over 65) of EU countries.

After a process of literature review and in-depth discussions with major stakeholders, frailty has been defined as a condition characterized by increased vulnerability and sensitivity to physical, psychological and social stressors, according to the bio-psycho social paradigm. Being frailty a reversible condition, the project focused especially on early detection and prevention, especially in primary care and community settings, in order to avoid disability and adverse outcomes.

Assessments conducted on Reference Sites Health and Social Systems and Services and related good practices allowed for the development of the Sunfrail Model on frailty and multimorbidity. At the same time, a specific appraisal indicated the necessity to consider older adults perceptions on frailty in order to bridge the gap between their needs and services available.
The review also pointed out also that a systematic assessment of frailty risk factors as well as the availability of specific tools for its early identification were missing; especially in primary care and community settings, leading to the design of the Sunfrail Conceptual Frame and of the Sunfrail tool.

The Sunfrail Tool is a nine-question, easy to use tool designed to identify frailty and multimorbidity according to the bio (physical), psycho (cognitive and psychological) and social domains. Based on the Sunfrail Conceptual Frame, the Sunfrail Tool can be administered by professionals and community actors, generating an initial “alert” for further investigations or activation of pathways within the health, social and community systems.

In order to facilitate the understanding and utilization of the Sunfrail Tool by social and health care professionals, the project has also designed the Sunfrail Tool for Human Resources Development; a short, multidisciplinary training programme on frailty and multimorbidity according to the bio-psychosocial model.

Within the Model experimental phase, the Sunfrail project conducted a further appraisal of identified good practices on population risk stratification (e.g.: Risk-ER), to measure how they could fit and enrich the designed Sunfrail Model of Care. The main outcomes were reduced hospital and emergency admissions for ambulatory care sensitive conditions. At the same time, the adaptability, usability and adoption of the Sunfrail Tool into Reference Sites current professional practice was tested, to verify the potential for replicability in EU countries.

The experimentation of the Sunfrail Tool involved 651 older adults over 65 years of age. The main results confirmed the capacity of the Tool to identify frailty and related risks in the population over 65, especially in primary care and community settings. The Tool appears particularly suitable to identify frailty risks in a population without clear signs of disability or not known by services and therefore is appropriate to orient the selection of preventive care pathways.

An assessment conducted on beneficiaries and professional opinions highlighted that the Sunfrail Tool is understandable, easy to use in every day practice, facilitating access and linking health, social and community services.

It proved to be effective in raising older adults awareness on frailty risk factors and on services available; in strengthening professional’s knowledge and approach to frailty; in facilitating the connections among existe

Methods and means

Coordination and management tools had been created by RER-ASSR, in collaboration with ASTER and EUREGHA, namely:
• Operational Plan
• Sharing of local, regional, stakeholders’ contacts and mailing list
• Internal project repository
• Financial reporting manual
• Meeting minutes
• Set of teleconference and update of to do list
• Activity memo and reminder
• Continuous risk assessment analysis and contingency plan definition
• Management of all the communication with the Project Officer and the REA
• Preparation of budget amendment

Specific support was given to partner for the technical and scientific coordination of the
Project through ad hoc communications and feed back to task/WP leaders on methodological
aspects and on deliverables produced.

Work performed during the reporting period

Recent developments – Technical Aspects

Development of the Model - WP4

From August 2015 the project has started the first step of the operational plan, meaning the literature review, the assessment of Reference Sites health and social systems and services, the appraisal of EIP-AHA good practices on frailty and multimorbidity and the assessment of patients/beneficiaries perceptions of frailty and barriers to care. The review provided indications on the gaps existent in terms of early identification, prevention and management of these conditions, especially in community dwelling settings, and allowed the design of a tool for the early identification of these conditions. This phase was complemented by the assessment of the human resources programmes and development of a specific model and tools.

Literature Review (WP4.1.2)
MACVIA French reference site of the EIP-AHA performed an international literature review, from July to October 2015.
A PubMed review was done on frailty and multimorbidity, reaching toward the general objective of Sunfrail project to improve the identification, prevention and management of frailty and the general care of multimorbidity in community-dwelling persons (over 65 years old). An Excel file was generated to extract the data. Four dimensions of frailty were identified: biophysical, psychological, social and environmental. Emphasis was put on the overlapping factors of the multidimensional perspectives of frailty. Frailty, although considered to be a distinct geriatric concept, shares close links with other concepts like multimorbidity or sarcopenia, as well as common psychological, social and environmental determinants.

Assessment of good practices (WP4.2.1)
Based on the work on good practices (GPs) conducted through the EIP-AHA initiative, the Sunfrail project has initially designed a set of criteria aimed to assess Sunfrail Reference Sites GPs on Frailty and Multimorbidity.
The applicability of these criteria was tested during the assessment of the good practices from the EIP-AHA initiative, conducted from December 2015 to March 2016, through 2 phases. During the first phase, an inventory of the existing repositories A3 (Prevention and early diagnosis of frailty and functional decline, both physical and cognitive, in older people) and B3 (Replicating and tutoring integrated care for chronic diseases, including remote monitoring at regional level) was made with data from 2013. Two Excel tables were created, based on the criteria agreed among partner: one table for A3 Good practices, one for B3 Good Practices. All GPs were referenced within the tables. 98 GPs were listed in the A3 compilation. 86 GPs were listed in the B3 compilation. Out of 98 A3 GPs, 45 were selected, divided into 5 main topics (screening frailty, ICT tools, management of frailty, nutrition, statistical & observational research around frailty). Out of the 86 GP from action group B3, 41 were selected, corresponding to 3 main themes (ICT, management, integrated approach/New health models, training workforce). A set of criteria was selected to enable the identification of services good practices. The results of the assessment of GPs indicates that the criteria initially designed for the identification of good practices needed to be revised, as GPs from the EIP-AHA initiative (A3 and B3) could not fulfil entirely these criteria. In particular, on the repository EIP-AHA there was a lack of information concerning multimorbidity and frailty or insufficient information concerning the practical applicability of the practice. Based on these aspects the criteria for the assessment of GPs were then revised.

The assessment followed with a second phase in which Sunfrail Reference Sites Good Practices on Frailty and Multimorbidity were assessed and a report produced. This step has been performed as part of the Deliverable 5.4 (Survey of RS service delivery).
Assessment of partners Health and Social Systems (WP 4.2.2)

From September 2015

The main output achieved so far and their potential impact and use by target group (including benefits)

Among the project main outputs are: the Operational definition of Frailty, the Sunfrail Model and Tool for the early identification of frailty and multimorbidity. The project has also developed a Model and a Tool for human resources development: a short educational programme, for frailty detection, prevention and management with a multidisciplinary approach.

The assessment conducted on Reference Sites Health Systems and Health and Social Services, on the beneficiaries perceptions and barriers to care, and on the identification of human programmes and needs related to frailty and multimorbidity, gave an overall view of the models of care available at Reference Sites participating to the Sunfrail project and contributed to design the Sunfrail Pre-Model for the identification, prevention, management and care of multimorbidity.

The results of the assessments indicates that there is an important need to “bridge the gap” between services provision and utilization, especially considering beneficiaries perception of frailty versus their expressed need to maintain independence, that influences their health seeking behaviour.
It is therefore important to focus on older people awareness on risk factors and preventive measures, and on improving professional’s knowledge and capacity to detect, prevent, manage and communicate frailty within a multidisciplinary effort.

The Potential for Innovation, Replicability and Sustainability

The proposed innovative Model and tools has allowed the assessment of the dimensions of frailty and multimorbidity, in different EU countries, following a multimodal scheme. It has provided to partner with a scenario of different approaches to care and good practices from which to adopt/adapt and complement their own schemes of care. It has supported the development of innovative tools for the early identification of frailty and prediction of multimorbidity according to the different level/entry point of care and with a tool for human resources development.

Replicability and sustainability has been ensured by the participation of all relevant actors (EU stakeholders, scientific community, services planning and delivery, decision makers and final beneficiaries), to all project’s design and implementation phases, including the main dissemination events (transnational workshops).
Particularly, the active involvement of EUREGHA (the European Regional and Local Health Authorities), of the European Union Geriatric Medicine Society (EUGMS) - working group on “Frailty in older persons”, and of internationally recognized experts in the field of frailty and multimorbidity (AB members), has supported the project development with necessary strength in terms of scientific knowledge, technical input and potential for dissemination and replication, thus ensuring a real added EU and international value.

The active involvement of relevant EIP-AHA networks (A3 and B3 action groups), in the assessment and dissemination phases, has ensured full complementarity with the actions already implemented within the EIP-AHA initiative and the sustainability of proposed actions.

Achieved outcomes compared to the expected outcomes

The impact of the action is intended as the changes in thinking, attitudes and processes enhancing Reference Sites capacity to sustain the activities beyond the project life (sustainability). It is reflected by the adoption of policies and strategies, the involvement and empowerment of key stakeholders and beneficiaries, the allocation of funding and resources, organizational changes and requests for replications and adoptions of the designed model and tools. The impact reported by each Reference Site is summarized below:

Emilia-Romagna Region

Institutional: describe if there was an involvement of key institutions at the sub national and national level and the related effects in terms of strategies, policies regarding the project’s objectives and expected results.

SUNFRAIL project achievements fit within Emilia-Romagna Regional Social and Health planning. Since 2007 Emilia-Romagna Region has been deeply involved in planning and organizing services addressing Population Ageing challenges with a particular focus on frailty and multimorbidity. The Regional commitment is demonstrated by the new 2015-2018 Regional Plan for prevention and the 2017-2019 Regional Social and Health Plan; by a number of policy actions ranging from prevention and management of frailty, chronic diseases, multimorbidity and falls, as well as health researches focused on aging. Furthermore, since 2013 Emilia-Romagna is participating as Reference Site to the European Innovation Partnership on Active and Healthy Ageing.

Intersectoral collaboration: describe the involvement of relevant sectors (health, social, community, others).
The 2017-2019 Regional Social and Health Plan, that has been recently approved, foresees to support the development of territorial and community health-care services, strengthening the role of primary health care facilities as a strategic hub for health and social integration.
Among the objectives of the Plan are listed: to establish policies to strengthen home care and community care settings; to encourage the autonomy of people within their life contexts; to improve the quality of health services and health expertise (including the skills needed to work in multiprofessional teams).
The Sunfrail model and tools are coherent with these purposes, and are raising a progressive interest and requests for replications by local stakeholders.

Allocation of Resources: describe if, as effect of the project activities, funding and resources were allocated to continue the activities beyond the project life.

The recently approved Regional Social and Health Plan indicate some national and regional resources allocated coherenty with SUNFRAIL purposes and results. Among them:
- the National Fund for Non-Self-Sufficiency (FNNA), established in 2006 (law n.296, 27th December 2006), with the aim of providing support to people with disabilities and to non self-sufficient older adults. The Fund promotes home-care, avoiding the risk of institutionalization and ensuring the implementation of the essential levels of welfare services.
- the Regional Fund for Non Self-Sufficiency (FRNA), to promote the development and qualification of the network of services for non self-sufficiency, and to support families and home-care of non self-sufficient people.

Multiplier effect: describe the changes in terms of replication and extension of good practices, model and tools.
Among the innovative instruments identified with the project, Risk ER good practice of Emilia Romagna has contributed to enrich the Sunfrail designed Model of Care due to its capacity to predict, identify and manage patients at high risk of hospitalisation and disability in primary care settings. The experimentation took place in 6 Community Health Centres (Case della Salute) where nearly 6000 people were identified through the risk profile algorithm (very high-high risk of hospitalization). The main outcomes were improved pathways for identification, prevention and care of f

Dissemination and evaluation activities carried out so far and their major results

Communication – Dissemination WP2
The dissemination plan was finalized in October 2015. It has the purpose to establish a structured and clear way to communicate and disseminate project results, both internally to partners and to external stakeholders and the general public. The strategy outlines communication and dissemination objectives, target groups, visual identity and promotional tools, online and social media, and networking events and tools.

Dissemination tools
In parallel with finalising the dissemination strategy, the visual identity of SUNFRAIL was developed. The project logo was finalised and has been shared with all partners. A Visual Identity Manual explaining how to use the logo was shared in September 2015.
The Project Website is available since early November 2015 at The website contains information about the project, the partners and work packages, the concepts of frailty and multimorbidity, a news section, a document section, an events calendar, a built in Twitter flow, link to the LinkedIn account and a contact form. The website is continuously updated with project news.

The website also has a built-in fully operational partner section with the function of an “intranet” where partners can upload documents and deliverables for mutual review.
A project brochure has been developed, which includes basic information about the project, with the aim of showcasing the project to stakeholders during relevant events. To facilitate local dissemination, all partners were asked whether they would like the brochure translated from English. After consulting the partners, French and Italian versions were produced. The project final brochure was developed to provide information about the project, the EU synergies, the main outcomes, the results of the experimentation and recommendations for future adoption and replications of the Sunfrail Model and tools.
The dissemination strategy foresees four newsletters, containing information about the project and related news and events. The newsletters were circulated to the stakeholders identified in the stakeholder mapping, and to EUREGHA members – regional and local health authorities across the EU.

Twitter and LinkedIn accounts for the project were created to raise awareness about the project in social media. Twitter has especially been used during project events and the LinkedIn group aims at gathering project partners and other interested stakeholders.

A stakeholder mapping document was created during the early phases of the project, to identify professionals and organisations that would be able to provide input to project activities as well as benefitting from project results. Stakeholders were mapped at European, national and sub national level. The stakeholder mapping has been continuously updated with contributions from partners and remains a living document identifying stakeholders which will receive updates on the project progress through newsletters.

To market the two SUNFRAIL Transnational Workshops in Bologna, Naples and the Final Conference in Bologna, a poster and an agenda were designed with the aim of marketing the events. Sunfrail shoppers with logos of the consortium were produced and distributed during the Final conference. A Layman version of the Final Report was also produced.

A PowerPoint template and a letterhead, following the project’s visual identity, were developed and are available for download on the SUNFRAIL website. Also a standard presentation was developed, including basic information about the project for partners to use to promote the project at external events. Apart from these tools, developed for external use, a template for deliverables was also produced for project partners.

Business cards were also developed and distributed to project partners, containing the project logo and contact information.

Sunfrail and related results have been presented to important project’s dissemination events such as:

Start date: 01/05/2015
End date: 28/02/2018
Duration: 30 month(s)
Current status: Finalised
Programme title: 3rd Health Programme (2014-2020)
EC Contribution: € 886 193,00
Portfolio: Ageing