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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
Coordination of the project by lead RER-ASSR

Start month:1 - End month: 30

The Leader will set up an organizational structure that will ensure the smooth implementation and quality of the project process and outputs. A Steering Committee (SC) made up of one representative of...
The Leader will set up an organizational structure that will ensure the smooth implementation and quality of the project process and outputs. A Steering Committee (SC) made up of one representative of each of the project partner, will be set up. Representatives will have to be delegated or be able to represent their organizations: in other terms they will have take binding decisions on behalf of the entity they are representing. Decisions will be taken by the SC based on voting: one member, one vote. When needed, to unlock situations and decisions, the vote of the Lead Partner will count twice.
The role of the SC is to provide general oversight functions of the project progress and take over the responsibility for adjusting the project during the implementation phase. The SC will be coordinated by the LP, which will be responsible for acting as the intermediary for all communications between the beneficiaries and the Agency, requesting and reviewing any documents or information required by the Agency and verify their completeness and correctness before passing them on to the Agency, submitting reports to the Agency, ensure that all payments are made to the other beneficiaries without unjustified delay, inform the Agency of the amounts paid to each beneficiary, when required in the MGA or requested by the Agency.
The SC will meet 5 times during project implementation. Ongoing communication will occur through streaming channels, Skype, emails as well as telephone

While all these activities will not be delegated or subcontracted, the LP will be supported by the linked Third Party to RER-ASSR, ASTER (TP1). Specifically, ASTER (TP1) will provide technical support in management procedures and will be in charge of running the Transnational Secretariat (TS) thus contributing to make daily action running in a smooth and effective way.
Apart from the above listed activities, the LP will lead Internal Communication and Decision Making (maintaining continuous and constructive communication between all partners, addressing any difficult or conflict situations that may arise, regular teleconferences); Administrative Co-ordination (the correct handling of contractual documents and the proper communication with CHAFEA); Financial Management (monitoring of the correct budget use through the web-based management tool); Reporting (reporting to the CHAFEA in accordance with requirements as per Grant Agreement).
The Transnational Secretariat (TS) will: a) support preparatory activities of transnational meetings: i) send reminders 1 month before each meeting, ii) ask hosting partner to provide info pack to facilitate partners in their travel and accommodation arrangements, iii) circulate agenda; b) be responsible for project document management: i) collect official documents, ii) store them on accessible and secure online web storage platforms; c) support project scheduling: i) open and update an online Project Calendar, ii) remind milestones deadlines to Activity Leading Organizations, iii) support Lead Partner in collecting evidences of Multiplying events and dissemination activities.
At scientific level, an Advisory Board (AB), coordinated by the Lead Partner, will be set up by the SC during the kick off meeting in Luxembourg. Subject to agreement of the SC, representatives from other stakeholders may also be invited to sit on the board. The role of the AB is to provide scientific guidance for project implementation and to support the SC at critical stages of the project and on any key challenging issues. The Advisory Board will meet 4 times during project implementation. Ongoing communication will occur through streaming channels, Skype, emails as well as telephone.
Project Partners will have to a) Keep information stored in the Beneficiary Registry up to date, b) Inform the coordinator immediately of any events or circumstances likely to affect significantly or delay the implementation of the action, c) Submit to the coordinator in good tim
Dissemination of the project by lead EUREGHA

Start month:1 - End month: 30

During the kick-off meeting a Dissemination Strategy (DS) and its related Dissemination Action Plan (DAP) will be discussed by all partners. The DS will address the issue of sustainability and will in...
During the kick-off meeting a Dissemination Strategy (DS) and its related Dissemination Action Plan (DAP) will be discussed by all partners. The DS will address the issue of sustainability and will include a stakeholder analysis and the definition of channels of communication.
The principles of the DS will be:
A) To guarantee a relevant impact at Eu level through an intensive Eu networking and “project alliance building” activity which will be targeted at least at the following organizations: a) European Innovation Partnership on Active and Healthy Ageing (EIP-AHA); b) WHO’s Regions for Health Network (RHN); c) Community Of Regions for Assisted Living (CORAL); ENGAGED – Community for Active and Healthy Living; Age Platform Europe; European Regions Research and Innovations Network (ERRIN) and specifically their Health Working Group: http://errin.eu/; Assembly of European Regions (AER); European Public Health Alliance (EPHA). Existing partners’ connections with other EU based organizations will also be used to extend the benefits of the project to other EU countries.
B) To extend and settle project dissemination and impact at local, regional and national levels. During the preparatory phase, project partners have already performed a first check of feasible and sustainable dissemination activities which should be implemented at local, regional and national levels and which could be the main actors to involve from the very beginning. These kind of dissemination actions will be guided by strong educational principles (especially on the professionals’ side), commitment to increase research capacities of local, regional and national research units focused on the project topic
C) To use the most appropriate dissemination “tools and means” according to the project phase: a) Electronic versions of project deliverables will be disseminated through surface mail, institutional websites and presented at relevant events: one official project brochure will be published when the project will be launched while an updated version will be introduced whenever key milestones will be reached.
D) To include evaluation as a key issue in the dissemination plan, to best try and assure that we are reaching the expecting target groups, and that the dissemination is well implemented.
E) To include evaluation of the efficiency of the dissemination by the project partners on a regular basis so that the dissemination plan can be revised and updated throughout the project if needed, to assure the efficiency of the dissemination
F) Interlinking with partners, such as making sure that the project’s website is interlinked with all the partners’ websites for increased visibility, but also with other relevant EU initiatives such as the website of the EIP-AHA
G) Overall, to not focus the main dissemination work on the final conference; i.e. to include for instance one workshop per year where the development of the project is discussed, workshops to where external stakeholders can be invited
H) To create an ongoing relationship between the AB and the most important external stakeholders that can provide feedback on a regular basis, for instance in meetings with said stakeholders

WP Leader, in cooperation with the LP, will
2.1 Conduct a detailed stakeholder analysis, including stakeholders at EU, national, regional and local level, at the very start of the programme so that the communication and dissemination can target all stakeholders from an early stage; 2.2 Adapt the method of dissemination after the different stakeholders, have a strategic “plan” of which communication channels that will work best for the different stakeholders, in order to improve the effects of the dissemination;
2.2 Develop a dissemination plan with the aim to raising awareness of the expected project results, promoting project results, and “translate” the project results to the different stakeholders that are targeted. The first version of the diss
Monitoring and Evaluation of the project by lead DEUSTO UNIVERSITY

Start month:1 - End month: 30

Monitoring is the regular and systematic collection of information (including those which relate to agreed indicators) that can then be measured against baselines and forecasts. Evaluation, however, h...
Monitoring is the regular and systematic collection of information (including those which relate to agreed indicators) that can then be measured against baselines and forecasts. Evaluation, however, has a wider scope and is important for assessing (and understanding) the achievements of the project. It addresses questions such as
i) To what extent and in what ways have the objectives of the project been met or exceeded;
ii) How effectively were the outputs achieved; and
iii) To what extent and in what way have the outputs contributed to appropriate outcomes (impacts).

The importance of the monitoring and evaluation WP cannot be easily overstated in view of the potential outcomes (impacts) that will affect the well-being of frail (mainly older) people and both their formal and informal carers. Linked with such outcomes (impacts) are the potential for the model developed to help facilitate a delay in the onset of frailty; greater equalization in access to health and social support services; and a reduction in the costs to formal health and social care services. Such matters are included in the range of performance measures to be refined and adopted within the project (see below).
At the outset a Monitoring and Evaluation Plan will be developed with clear terms of reference. The Plan will include a summary description of the context; the background requirement; the approach being adopted; and timetables for the same. It will identify the indicators for which monitoring information will be required and arrangements for reporting. Some of the indicators may be designated as carrying especial importance and, therefore, carrying ‘priority’ status. The Plan will, furthermore, set out what evaluation activity will take place throughout the life of the project. For both monitoring and evaluation, the responsibility of all partners to gather necessary information (including that which is provided by the stakeholders with whom they have contact) and feed it into the monitoring and evaluation process will be emphasized. More than this it will clearly state the nature and extent of detail required for such information. That information will be available for scrutiny by the Project Coordinator and by the Advisory Board.
To help partners in planning the way they feed into the monitoring and evaluation process the Monitoring and Evaluation Plan will incorporate a ‘Delivery Profile’ that will be updated throughout the project – both facilitating and prompting the necessary inputs. It will also provide a guideline, as appropriate, in relation to the way that partners utilize what, in some cases, will be personal data (e.g. from their involvement in ‘Reference Sites’ (per the EIP-AHA) or ‘Validation Sites) in accordance with data protection requirements (and any new guidance).
A comprehensive (Excel) spreadsheet will be maintained in relation to the monitoring and evaluation tasks – and will be available to all project partners. Interim Monitoring and Evaluation reports will be produced – also giving information on issues that have been encountered and lessons learnt. The Interim reports will support the Lead Partner in its reporting to CHAFEA.
Performance measures (PIs) that will be put in place for the project will cover the following areas.
They will endeavour, at all times, to reflect the holistic perspective taken by the project. This, of course, broadens out from any ‘narrow’ biomedical or physical perceptions of frailty and encompasses the position of people aged over 65 who are frail in community settings.

• The range and authority of sources of information drawn upon (from within the EIP AHA network and beyond) that provide a meaningful context for fulfillment of the project’s objectives; with account taken of their attention to
o frailty in community settings
o integrated approaches involving health and social care
o environmental contexts (housing accessibility, assistive technologi
Design a model for frailty identification, prevention and care and management of multimorbidity by lead RER-ASSR

Start month:1 - End month: 15

Main methods and means:
- Desk Analysis (incl. analysis of secondary data)
- Analysis of EIP-AHA action groups (A3, B3), initiatives outcomes and tools
- Workshops with stakeholders at regional and n...
Main methods and means:
- Desk Analysis (incl. analysis of secondary data)
- Analysis of EIP-AHA action groups (A3, B3), initiatives outcomes and tools
- Workshops with stakeholders at regional and national level
- Group Discussions
- Other

TASKS
4.1 Opening: Organizing a transnational Workshop (M1-M2)
4.1.0. Collect necessary evidence to be shared during the transnational workshop
4.1.1. Organize a transnational workshop with PPs, relevant institutions and collaborating stakeholders, to share the objectives of the project and to involve them through key moment of the implementation.
4.1.2 Identification of a shared definition of domains approaching frailty through their health, socio-economical and environmental aspects, by participating institutions and stakeholders.

4.2 Modelling – Phase I (M2-M6):
4.2.1 Analysis of the tools, findings and recommendations resulting from the EIP-AHA initiatives on frailty and multimorbidity (Action Groups A3 and B3) and of constraints to effective implementation. (M1-M2)
4.2.2 Assessment of partner’s social and health systems (international literature review, scientific evidences) (M3)
4.2.3 Develop the pre-model and adapt tools (with its social, health, economic and educational dimension): all dimensions of PPs running models are put together (M2-M4)
4.2.4 Develop innovative tools for predicting frailty and multimorbidity and to assess their costs (M2-M6).

4.3 Modelling Phase II (M11-M15)
4.3.0 International literature review to assess effectiveness of RS practices (M11-M12)
4.3.1 Review and validate the model based on the results of the WP5 (M11-M14)

4.4 Organize a transnational workshop to share the model (M15)

Validating the model by lead GERONTOPOLE

Start month:1 - End month: 10

Main methods and means:
- Qualitative investigations (Focus Groups, others)
- Analysis of secondary data (services delivery, results of EIP-AHA assessment)
- Quantitative investigations (if needed)...
Main methods and means:
- Qualitative investigations (Focus Groups, others)
- Analysis of secondary data (services delivery, results of EIP-AHA assessment)
- Quantitative investigations (if needed)

TASKS
5.1 Analyse the results of EIP-AHA initiatives on the assessment of patients/final beneficiaries on perception on frailty and multimorbidity and expectations for care and quality of life (M1);

5.2 Prepare and conduct complementary investigations (qualitative research methods) (M2-M3);

5.3 Develop/adapt instruments and tools for the assessment of RS service delivery (M3-M6)

5.4 Survey of service delivery: identification of good practices and usual care (M7-M10):
5.4.0 Data collection and analysis:
5.4.1 Secondary data collection: data sources (AGs A1, A3, B3, services delivery and information systems HIS).
5.4.2 If necessary, conduct complementary quantitative investigations
5.4.3 Data analysis and reporting

5.5 Assessment of the human resources development programmes and tools (see details in WP 7) (M3-6)
5.5.0 Elaborate tools
5.5.1 Perform the assessment
5.5.2 Review and adapt the tools

Experimenting the model by lead HSCB

Start month:16 - End month: 30

Main methods and means:
- SUNFRAIL will experiment the application of the frailty model through a number of operational structures including existing frailty units, Living Labs, and other structures ...
Main methods and means:
- SUNFRAIL will experiment the application of the frailty model through a number of operational structures including existing frailty units, Living Labs, and other structures available in each participating region
- The experimentation will apply the outputs from WP5 which will include(frailty and multimorbidity predicting tools, guidelines for professional performance improvement, ways of multi-disciplinary working and integration
- Explore an analysis of costs

TASKS
6.1 Identify the operational structures supporting experimentation (frailty units, living Labs, others), most applicable at Regional/local level (M16). Each partner will select the operational structure more suitable to own specific context.

6.2 Experiment the model, through specific units, living labs or other operational structures (pilot); partners will decide whether to adopt/adapt the elements emerging from the model according to their specific needs. (M16-M27)
6.2.1 Selection of “pieces of the full model” to be tested or further analyzed
6.2.2 Identify system/services good practices and weaknesses
6.2.3 Develop an operational plan
6.2.4 Experimentthe tools for frailty and multimorbidity early detection (slow gate speed, multimorbidity predicting tool, others). (M16-M27)

6.3 Improve knowledge and challenge human resources to produce new working methods (M16-27)

6.4 Review and adapt the Model and the application of the tools
(frailty and multimorbidity predicting tools, educational tools, analysis of costs, data sets, pathways of care, etc.).

6.5 Assess and ensure its sustainability, replicability and transferability at EU level. Ensure institutional, operational and economic sustainability of the Model through the involvement of relevant institutions, policy makers and patients (accompanying measures) (M16-M30 )

6.6 Monitor how experimentations can produce better results/evidences:
Testing
- Services
- Economic dimension
- Educational dimension
- Health dimension

WP2 RELATED ACTIVITY
- Organization of a transnational event to disseminate the results of the sperimentation (M30)
- Planning for local/national advocacy initiatives – M30/M31



Healthcare staff innovative education by lead REGIONE PIEMONTE

Start month:1 - End month: 30

Professionals are falling short on appropriate competencies for effective team work’ (The Lancet Commission on health professionals’ education). In almost all countries the education of health pr...
Professionals are falling short on appropriate competencies for effective team work’ (The Lancet Commission on health professionals’ education). In almost all countries the education of health professionals has failed to solve the dysfunctions and inequities in health systems due to, among other things, curricular rigidities and professional silos. By interprofessional education we mean learning ‘from and about each other’ in order to improve collaboration. Of course, shared learning on common topics can be a first step to real integrated team-based education.

See 5.4 Assessment of the existing human resources and their respective training and educational background

The work will be carried out in close cooperation with the European Innovation Partnership Action Group B3, Activity Area 3: ‘Workforce Development’.
Building upon the AA3 mapping of good practices at EU level, regarding the existing training and academic programmes for healthcare professionals in the different countries, a synthesis of the best experiences and training models coming out from the mapping will be carried out.
This workpackage will be cross-sectional throughout all the different areas and domains considered in the project planning.

Along with the overview and analysis of existing care models in the specific context of frailty and pre-frailty, together with the experts involved in the project WPs, specific features regarding the training of healthcare students/staff will be designed. Healthcare staff training design would have to follow the best and most effective care models’ needs. The project experts involved will develop an innovative experimental educational model, in coherence with the experimental innovative care model developed in WP 4.
Medicine students, psychologists, pharmacists and nursing students’ existing curricular contents will be analyzed, in order to identify the gaps existing with the staff training needs working in the context of a possible ‘ideal’ care model, focused on prevention, identification and care of frailty.
Focus on polypharmacy/multitherapy: The physiological age-related decline, through the gradual reduction of functioning of the body, causes the onset of progressive frailty together with multimorbidity. For this reason, polypharmacy plays a crucial role in the life of the elderly, affecting the perceived QoL and the degree of frailty.

Among the different methods proposed to implement rationalization of polypharmacy, the strategy of optimizing the use of drugs by increasing in the healthcare staff the knowledge of such valuable tools as medicinal products are , is currently surprisingly underestimated. In fact, despite scientific research increases continuously information about properties of drugs, too often the training of the healthcare team (GPs, nurses, pharmacists) and of students from different health education degree courses is docked to traditional patterns with limited application contents

GOAL: Focusing attention to the development of innovative training methods can be translated into an effective tool for preventing frailty and for improving perceived QoLin the elderly, through the reduction of polypharmacy-induced critical issues. Overcoming the limitations of traditional education models, our objective is the implementation of a continuous, experiential, measurable and productive training system:

Continuous: for undergraduates (students from different graduation courses), postgraduates (internship, master degrees), and professionals (healthcare staff);

Experiential: learning will be based on experience, through the application of acquired skills and the continuous revision of previously acquired concepts according to what is experienced;

Quantifiable: the IT tools used by different healthcare professionals (prescribing and dispensing data collection, medical records) will allow a direct assessment of the implementation of good practices in prescrib
Details
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