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Social Engagement Framework for Addressing the Chronic-disease-challenge [SEFAC] [738202] - Project
Coordination of the project by lead EMC

Start month:1 - End month: 36

Task 1.1: Monitoring and steering (Month 1 – Month 36).
Lead partner: EMC; Contributors: all.
This WP will monitor the activities and progress towards deliverables of all WPs. Where needed, it will...
Task 1.1: Monitoring and steering (Month 1 – Month 36).
Lead partner: EMC; Contributors: all.
This WP will monitor the activities and progress towards deliverables of all WPs. Where needed, it will give advice to the WP leaders in order to ensure that the objectives of their WP are reached. Threats to progress of the project will be analysed and, if needed, discussed at a Steering Committee (SC) meeting to find solutions.

Task 1.2: Action plan, ethical standards and independent Advisory Board (Month 1 – Month 36). Lead partner: EMC; Contributors: all.
The SC, which constitutes of all main and associated partners produces a detailed action plan, appoints a quality manager, monitors the progress, and discusses problems with the progress of specific WPs. The Ethical Standards Committee sets and monitors ethical guidelines. An independent Advisory Board convenes at month 9, 21 and 34 and advises on the optimal course of the project and dissemination of results.

Task 1.3: Internal and external communication and Steering Committee meetings (Month 1 – Month 36).
Lead partner: EMC; Contributors: all.
The WP organises communication within the project and with external parties (with WP2) using personal visits, e-mail, telephone contact, newsletters, web conferencing facilities and the project website. The WP will organise 6 Steering Committee (SC) meetings at the premises of the Executive Agency in Luxembourg: kick-off meeting at month 3, and meetings at month 9, 15, 21, 27, and 34; the entire consortium meets at month 9 and 34.

Task 1.4: Financial and administrative issues (Month 1 – Month 36).
Lead partner: EMC; Contributors: all.
This WP will handle all financial and administrative issues. The WP will prepare Interim technical and financial report according to the requirements of the European Commission. This WP will also ensure all other communication with the European Union, particularly with DG-SANCO.

Dissemination of the project by lead ELISAN

Start month:1 - End month: 36

Task 2.1 To establish and implement an outreach plan based on a stakeholder analysis. (Month 3)
Task 2.2 To set up and update the project website. (Month 1-3)
Task 2.3 To help organise triggering ev...
Task 2.1 To establish and implement an outreach plan based on a stakeholder analysis. (Month 3)
Task 2.2 To set up and update the project website. (Month 1-3)
Task 2.3 To help organise triggering events. (Month 1-36)
Task 2.4 To distribute dissemination materials. (Month 1-36)
Task 2.5 To set up and coordinate the activities of an Advisory Board (Month 1-36)

Methods: This WP will ensure strong communication and optimal dissemination of the project’s activities and outcomes by sharing the significant learning arising from the project’s activities, and by promoting all successes and outcomes. Partners will closely work with internal and external stakeholders, including end users, to develop an outreach plan and a set of supporting narratives for the project communication.
In collaboration with WP1, an attractive and functional project website (month 3) will be established by the Coordinator (EMC) for internal and external communication and dissemination. The site will include social media exchanges (blogging facility, links to Twitter, Facebook, LinkedIn), and will serve as platform for project results to support stakeholders. Using this social media approach, a network of involved experts, policymakers, practitioners and end-users will be set-up that will be consolidated as ‘European SEFAC Alliance’.

Synergies and links will be ensured with the Covenant on demographic change which is closely cooperating and building on existing initiatives such as the AFE-INNOVNET Thematic Network on innovation for age-friendly environments, WHO Global Network on Age-Friendly Cities and Communities, the WHO-Europe Healthy City Network, the European Innovation Partnership on Active and Healthy Ageing, in the spirit of the 2013 Dublin Declaration on Age-Friendly Cities and Communities in Europe.
Connections will also be in place with the ENSA European Network of Social Authorities. A final conference (month 36) will be organised in Brussels to present the project’s outcomes and to discuss strategies for innovative community involvement of citizens in order to prevent and manage chronic conditions.
Partners will use their dissemination channels to share information related to the project’s outcomes, and will disseminate materials on the project. To do so, ELISAN, in cooperation with EMC (coordinator) will develop appealing communication materials including a promotional leaflet. Dissemination activities will be supported by the preparation and large diffusion of SEFAC bi-annual newsletter. The newsletter will contain inputs by all partners and interviews with EU authorities, health and social care professionals.

A publication (month 36) including a list of innovative practices and policies, together with policy recommendations (WP9) and the project’s key findings for transfer and scale-up will be presented at the final conference of the project in Brussels (month 36) together with a tool box (WP9). An Advisory Board will be set up with external Authorities, ENSA experts and AGE experts to add additional inputs on chronic conditions prevention and ageing as well as to give feedback on the project’s activities.

Evaluation by lead UVEG

Start month:1 - End month: 36

Task 3.1. Evaluation of achievement (Month 1- Month 34).
Lead partner: UVEG; Contributors: all.
In this task the achievement of the objectives will be assessed and the indicators for the achievement...
Task 3.1. Evaluation of achievement (Month 1- Month 34).
Lead partner: UVEG; Contributors: all.
In this task the achievement of the objectives will be assessed and the indicators for the achievement will be evaluated. Project progress will be monitored to ascertain achievement of all objectives by the WPs. Incomplete achievement will be evaluated for its causes and possible consequences and discussed with the WP leader and the SC.

Task 3.2. Monitoring of the project execution (Month 1 – Month 36).
Lead partner: UVEG; Contributors: all.
Through this task it will be monitored the completion of deliverables and commitment to project objectives. If deliverables cannot be attained at the proposed timing, the causes and possible consequences will be evaluated and discussed with the WP leader and the SC.

Task 3.3. Evaluation of the implementation at the 4 pilot sites (Month 10- Month 24).
Lead partner: UVEG; Contributors: all.
This task will ensure that the 4 pilots within the project are well-organized, conducted and evaluated. During mutual site visits (month 18-20) according to an agreed-upon visitation protocol, the implementations will be evaluated. The resulting reports will serve as feedback and be used for mutual learning to increase the quality of pilots.

Task 3.4. External evaluation (Month 18 – Month 34).
Lead partner: UVEG; Contributors: all.
In addition to an internal evaluation, we will include and external evaluation including consultation of end users, volunteers, and other relevant stakeholders. We will specify the criteria with regard to: (a) Perceived effectiveness: The extent to which the project achieved its specific objectives and goals according to the stakeholders; (b) Perceived efficiency: The extent to which the project used its resources efficiently, and provided value for money according to the stakeholders; (c) Perceived utility: The extent to which the project has a potential impact on the main target groups specified, according to older citizens, professionals, managers and policy makers. (d) Perceived sustainability: The extent to which the project has led to sustainable changes or benefits that will last after the project has been completed according to the stakeholders.
Deliverables linked to this work package (brief description, month of delivery, reference to the list of deliverables)
Deliverable 3.1. Interim evaluation report (together with WP1) Month 18
An interim evaluation report according to the described work will be issued to be included in the interim technical report elaborated by EMC.
Deliverable 3.2. Final evaluation report (together with WP1) Month 36
A final evaluation report according to the described work will be issued to be included in the final technical report elaborated by EMC.

Design and preparing for Scaling up a successful Social Engagement Framework (including the involvement of volunteers) for chronic diseases prevention and management at community level by lead AGE UK

Start month:1 - End month: 14

Task 4.1. Assess the needs of citizens at risk for major chronic diseases as well as those that already have a major chronic diseases (aged circa 50 years or older) for delivery with voluntary and com...
Task 4.1. Assess the needs of citizens at risk for major chronic diseases as well as those that already have a major chronic diseases (aged circa 50 years or older) for delivery with voluntary and community services, using a variety of methods (Month 1 - Month 14).
Lead partner: AGEUKCORNWALL; Contributors: all.
In this task the objective will be to review current methodologies for identifying people at risk of co-morbidities that would respond to a community based service. E.g., risk stratification, use of learning cafes, primary care practitioner applied criteria. Following the determination of the selection methodology, the Living Well ‘guided conversation’ approach is used to identify peoples support and care needs and will be tested against other recognised methodologies.
Following the guided conversation, a care and support plan is developed and implemented with voluntary and community services.

Task 4.2.Develop an implementation plan that discusses extensively the implementation question and how to involve the stakeholders in the implementation phase of the scale up process. (Month 1 – Month 14)
Lead partner: AGEUKCORNWALL; Contributors: all
Stakeholders and partners involved in each of the sites, will be engaged in the development of the programme implementation plan, as well as the site implementation plans, which will build on the task described in 4.1 and will detail how we will:
1. Engage frontline practitioners in designing and building the model.
2. Involve citizens, including volunteers, in the design and build.
3. Work with the teams of practitioners and citizens to develop a team charter.
4. Identify key individuals in communities, professions and provider organisations.
5. Develop a culture of reflective learning and practice for all those involved.
6. Identify and develop best practice to report on outcomes for individuals.

Task 4.3 Create a training plan and a train the trainers’ plan for adoption and implementation of the Social Engagement Model (including the involvement of volunteers). (Month 1 – Month 14).
Lead partner: AGEUKCORNWALL; Contributors: all.
The training programme will be developed, giving specific focus on:
1. Wellbeing.
2. Guided conversation.
3. Communication skills.
4. Tools and techniques.
5. Assessing the achievement of outcomes for individuals.
As a result of participants undertaking the training they will be competent to train practitioners to change their practice in line with the Living Well principles and methodology.

Task 4.4 Deliver training sessions for the Social Engagement Model (including the involvement of volunteers) in the pilot sites.
(Month 12- Month 14).
Lead partner: AGEUKCORNWALL; Contributors: all.
A series of train the trainer sessions will be led by Age UK Cornwall in each of the chosen sites and ongoing support to ensure understanding and clarity will be given through Skype and other IT solutions.
An action learning set will be established with all sites, to develop a peer support network and the sharing of the learning experience, to ensure consistency of approach and delivery.

Create a training plan for healthy lifestyle behaviour adoption by lead ISRAA

Start month:1 - End month: 14

Task 5.1 Define the training methodology to increase among the population the awareness about chronic diseases leading risk factors and main prevention strategies (Month 1- 14)

Task 5.2 Define t...
Task 5.1 Define the training methodology to increase among the population the awareness about chronic diseases leading risk factors and main prevention strategies (Month 1- 14)

Task 5.2 Define the methodology to trigger behavioural changes among the population involved. (Month 1 – Month 14).
Lead partner: ISRAA
On the basis of the model of community as agent of change, it is defined a methodology to foster the natural supportive and developmental capacities of the community to find internal resources.
In order to better meet the needs of the community members, neighbourhood and volunteering organizations, wellness organizations, peer-to-peer support programmes and social networking are taken into account as possible ways of addressing behavioural changes in an ecological perspective.

Task 5.3 . Define, according to WP4
a. The size and the composition of training group target, in particular the percentage of health workers, social workers, volunteers and citizens to involve in the programme in each pilot site (Month 1 – Month 14).
b. The target groups (and their composition; i.e. individuals’ profile mix) covered by the SEFAC programme (Month 1 – Month 14).
Lead partner: ISRAA
Following the result of WP4 and according to it, the exact composition of the team is defined, in particular :
- how many and which health professionals should be involved in each team/pilot site
- how many and which social professionals should be involved in each team/pilot site
- how many citizens, and volunteers in particular, should be involved in each team/pilot site.

Task 5. 4 Create an integrated plan of actions and training timing schedule to deliver in the community in order to arise the individual awareness and to empower a better self - management of health (Month 1 – Month 14).
Lead partner: ISRAA
The integrated plan of actions will be created and developed, connecting the Living Well principles and where applicable supported by elements of the Mindfulness approach, in order to support people to accept the lifelong development of their health, even when it involves the (self – management of) chronic diseases, frailty and multi - morbidity.

The acceptance and the awareness of chronic conditions could positively enhance the motivation to reinforce self-management of health and lifestyles
Actions to be delivered at the community level, in each pilot site, are:
- Physical and cognitive training, given both in individual sessions and group activities. Each intervention will be tailored on the basis of an initial assessment.
- Where applicable (elements of) Mindfulness courses according to established quality criteria (MBLC, Mindfulness based living course)
- Intergenerational activities and activities that are an expression of solidarity among generations
- Peer-to-peer activities between involved actors in the local community.
- Networking between cultural, volunteers and other association already active in the local community in order to support actions about healthy lifestyles
- Supervision and coordination of solidarity actions oriented to support and help vulnerable categories/families/people and permit them a healthier lifestyle

Development of ICT tool to support the implementation of the SEFAC model by lead VIDAVO

Start month:3 - End month: 25

T6.1 SEFAC ICT Services Specification and Infrastructure Architecture (Lead partner: VIDAVO) (Month 3 – Month 4).
This task involves the specification of the services that will be enabled by the SE...
T6.1 SEFAC ICT Services Specification and Infrastructure Architecture (Lead partner: VIDAVO) (Month 3 – Month 4).
This task involves the specification of the services that will be enabled by the SEFAC ICT tool and the infrastructure architecture that will support the intended services. This specification will be based on the user requirements of the target groups of the proposed intervention. The output of this task will be used as the basis for the implementation of the SEFAC online platform and mobile app that will be used in the pilot phase.

T6.2 Implementation of the first prototype of the SEFAC online platform and mobile app (Lead partner: VIDAVO) (Month 5 – Month 10).
In this task, the first prototype of the SEFAC ICT tool will be implemented according to the specifications defined in T6.1. The SEFAC ICT tool will support chronic disease prevention and management through a mobile app, connected wireless medical devices (blood pressure and glucose meters) and lifestyle sensors, and a cloud big data predictive analytics platform. The mobile app will provide goal setting and review, coaching and motivation and will enable the user to register and self-manage various health and wellness parameters. More specifically, through the app and with the help of questionnaires, users will be able to monitor their nutrition and physical exercise and manage their dietary/physical activity goals on a health/activity calendar. They will also receive reminders, notifications, and motivational messages derived from the analysis of big volumes of registered personal data (registered with permission only), as well as consultation for commitment to healthier lifestyles in order to prevent or delay the onset of a disease and slow down or even reverse the progress of the disease(s), in line with their personalized dietary and activity goals. The SEFAC ICT tool will be available in four languages, i.e. those of the pilot sites (English, Dutch, Italian, and Croatian).

T6.3 Implementation of the final version of the SEFAC online platform and mobile app (Lead partner: VIDAVO) (Month 11 – Month 13).
This task will result in the final version of the SEFAC online platform and mobile app that will be used in the pilot phase to support the envisaged intervention. The first prototype that will be prepared during T6.2 will be subjected to user testing by a small number of users belonging to the target groups from each pilot site and will be refined and fine-tuned properly according to the received feedback, resulting in the final version and ensuring that the SEFAC ICT tool is ready for the pilot operation. Test protocols will be based on predefined scenarios taking into account all relevant aspects and required functionalities that need to be provided in order to efficiently address the targeted users’ needs.

T6.4 Preparation of the SEFAC app user manual and pilot staff training (Lead partner: VIDAVO) (Month 12 – Month 13).
This task involves the preparation of the user manual for the SEFAC ICT tool that can be used by the end-users at the pilot sites. Given that the app will be user-friendly and mostly self-explanatory, the user manual will be delivered in English, including however screenshots of the interface in the other two pilot languages. The pilot staff training for the SEFAC ICT tool will also take place in the context of this task. Given that a train-the-trainer approach will be followed, in this task, the pilot site trainers will be trained in the use of the SEFAC ICT tool, the functionalities provided according to the user’s role and the monitored condition, as well as first level technical support in order for them to be able to handle first level technical issues that the end-users might face. To this end, a training workshop will be organized by VIDAVO for the pilot sites trainers, who will be further supported through webinars.

T6.5 SEFAC platform operation, maintenance, and technical support (Lead partner: VIDAVO) (Month
Pilot site SEFAC implementation by lead MEDRI

Start month:10 - End month: 34

MEDRI will coordinate the implementation phase of four pilot sites: (a) City of Rijeka, Croatia; (b) Treviso, Italy; (c) Rotterdam, the Netherlands; and (d) Camborne/Redruth, Cornwall, United Kingdom....
MEDRI will coordinate the implementation phase of four pilot sites: (a) City of Rijeka, Croatia; (b) Treviso, Italy; (c) Rotterdam, the Netherlands; and (d) Camborne/Redruth, Cornwall, United Kingdom. These 4 pilot sites will implement and contribute to the evaluation of the integrated SEFAC model, based on the preparations in WP4, WP5 and WP6. In each pilot site, there is a local pilot site coordinator. All partners will give their contribution during the SEFAC pilot site implementation as shown below:

T7.1 - Age UK Cornwall staff, according to the WP4 deliverables D4.3 and D4.4 will run training sessions in each pilot site to heighten the skill of workers belonging to the pilot site partners, teaching them how the Social Engagement Model and involvement of volunteers works and how it should be adapted in the social context of the local community for its final delivery. Age UK Cornwall will give supervision and support to the local pilot leaders to ensure the alignment of activities to the right model adoption. (AGE UK and ISRAA, MEDRI, EMC, AGE UK pilot site) (Month 10 – Month 34).

T7.2 - ISRAA staff, according to the WP5 deliverables D51 and D5.2 will support local train the trainers courses aimed to give the knowledge about how to build up a training to change the lifestyle health behaviors. Also ISRAA with VIDAVO will present to each pilot team how to run help people in using ICT devices, data tracking and alarm information provided by the SEFAC ICT support platform. After training, ISRAA and VIDAVO will give a permanent supervision of the ongoing training implementation, in each pilot site, supporting its adaptation. (ISRAA and AGE UK, MEDRI, VIDAVO, EMC) (Month 10 – Month 34).

T7.3 – In each pilot site will be ensured a local volunteers campaign for recruiting at least a team of 20 volunteers that will take part in SEFAC’s activities regarding: over 50s social engagement to the Project’s events and/or following them at individual level. Supporting local team leaders in the delivery of assessment sessions, training/supporting all the local stakeholders. Also, barriers between target population and the opportunities to get in touch with services and other commodities that are provided will be diminished by coordinated SEFAC efforts. (ISRAA, MEDRI, EMC, AGE UK) (Month 10 – Month 34).

T7.4 - Build up community connections with local stakeholders: firstly with GPs, associations, pharmacies, shopkeepers, Municipalities and other health and social care providers to involve them in the SEFAC model and to establish a regular communication and interaction structure that helps citizens, engaged in the target groups, to get services and opportunities according to the individual needs and personal health plan that will be defined. Also GPs will be asked to join the local pilots by inviting citizens that they take care of, that could fit the target groups, to SEFAC’s events and interventions groups. (ISRAA, MEDRI, EMC AGE UK, VIDAVO) (Month 10 – Month 34).

T7.5 - Organize, deliver and monitor open events (4 at least) and thematic groups on major diseases self-assessment promoting the social engagement in the training courses on healthy lifestyles (define din WP5). The aim is to reach, in public events, 250 citizens (aged circa 50 years and older) in each pilot site, and having (net) 50 participants at risk of chronic disease and (net) 40 with chronic diseases that will join SEFAC’s interventions groups. (ISRAA, MEDRI, EMC, AGE UK with partners) (Month 10 – Month 34).

T7.6 - Implementation of thematic SEFAC’s groups interventions provided by WP5 with the local pilot site organization support also delivering ICT Apps tools (ISRAA, MEDRI, EMC, AGE UK,VIDAVO) (Month 10 – Month 34).
Starting month 14, each local pilot site [(a) City of Rijeka, Croatia; (b) Treviso, Italy; (c) Rotterdam, the Netherlands; and (d) Camborne and Redruth, Cornwall, United Kingdom will build up three interventions groups working on
Evaluation of the SEFAC model to address the prevention and intervention of major chronic disease by lead EMC

Start month:10 - End month: 34

WP8 follows the CDC-Framework for Programme Evaluation (Atlanta, 1999), including two perspectives: (a) end-users (citizens/participants at risk for and with a major chronic disease) and (b) care prov...
WP8 follows the CDC-Framework for Programme Evaluation (Atlanta, 1999), including two perspectives: (a) end-users (citizens/participants at risk for and with a major chronic disease) and (b) care providers including social and supportive service providers, and volunteers. The design: a classical Pre-Post design, with the added possibility to use the “in progress” monitoring data for the ICT-using subgroups (D. Kember, To control or not to control. Assessment and Evaluation in Higher Education 2003; 28:89–101; Stat Med 1989;8:455-66).

WP8, in collaboration with WP7, assesses:
(a) How well SEFAC is adopted and key elements are delivered (intervention integrity) (Psychol Schs 2005;42:495-507).
(b) The reach of the target population, and the participation of the pertinent stakeholders, especially the volunteers.
(c) Functioning of the social engagement toolkit as instrument of community based interventions in the four regions/countries.
(d) Functioning of the ICT support tool as part of the SEFAC in the four regions/countries.
(e) Benefits of the end-users in terms of healthy life styles, social participation, level of independence, health-related quality of life (EuroQol) and well-being (JAMA 1995;273:59), appropriateness of medication, use of ambulatory, residential and social care (Ann Intern Med 2003;138:288).
(f) We will measure the costs in order to perform a cost-effectiveness analysis. Direct and indirect costs will be measured (i.e., a societal perspective is adopted). We will account for the direct health and social care costs of each intervention element. Costs will be collected from care registrations; we will include costs of employment, material and equipment. Direct and indirect non-care costs will also be determined.

The plan for evaluation (recruitment; intervention definitions, measurements) is developed in collaboration with all stakeholders. In collaboration with WP7, per pilot site 250 citizens will attend community events regarding health and the prevention and management of chronic disease. They will be invited to screen for risks for chronic disease, in collaboration with the primary health care centres. Per pilot site (net) 90 participants at risk for (n=50) and with (n=40) a major chronic disease will be included in the SEFAC interventions after providing informed consent, and will participate in one or more group activities and/or ICT modules. Medical ethical approval will be obtained in each pilot site. We will monitor adverse effects (with WP1). Data collection will done at baseline and follow-up: participants (and relatives) are invited to complete questionnaires (though a dedicated App, web-based, paper or oral) regarding outcomes and process at baseline (month 14-22) and follow-up (month 26-34). Also data obtained through the ICT modules, with the informed consent of the users, will be obtained for “in progress” monitoring data for the ICT-using subgroups. Analysis and report will be performed.

Task 8.1 Inclusion of 4*90=360 citizens/participants at risk for and with a major chronic disease who provide informed consent to participate in SEFAC in the four regions/countries (Month 14 – Month 22).
Lead partner: EMC; Contributors: ISRAA, MEDRI, VIDAVO, AGE UK,ELISAN, UVEG

Task 8.2 Data collection at baseline and at follow-up and collection of registered (ICT) data with informed consent of the participants (Month 14 – Month 34).
Lead partner: EMC; Contributors: ISRAA, MEDRI, VIDAVO, AGE UK, UVEG, ELISAN.

Task 8.3 Analysis and report regarding the evaluation of the innovative SEFAC model to address the prevention and intervention of major chronic disease by community based interventions 4 European pilot areas: (a) City of Rijeka, Croatia; (b) Treviso, Italy; (c) Rotterdam, the Netherlands; and (d) Region of Cornwall, United Kingdom. (Month 18 – Month 34).
Lead partner: EMC; Contributors: ISRAA, MEDRI, VIDAVO, AGE UK, ELISAN, UVEG.

Integration of results and development of a toolbox for the SEFAC model by lead UVEG

Start month:30 - End month: 36

Task 9.1 Integration of results (Month 30-Month 36).
UVEG will lead the integration of results of WP 4,5,6,7 and 8 in tight coordination with the WP leaders and with the contribution of the rest of t...
Task 9.1 Integration of results (Month 30-Month 36).
UVEG will lead the integration of results of WP 4,5,6,7 and 8 in tight coordination with the WP leaders and with the contribution of the rest of the partners. This work will serve as foundations for the production of the SEFAC toolbox to facilitate transferability and implementation in EU cities and regions.

Task 9.2 Toolbox (Month 30-Month 36).
The toolbox will be developed by combining and discussing the meaning of the results of WP 4,5,6,7 and 8. Preliminary drafts of the tools to be included in the toolbox will be discussed with selected users agreed-upon the partners and relevant stakeholders among collaborating partners and experts. After adaptation, pre-final drafts of the tools will be discussed by the Advisory Board.

Task 9.3 Policy briefs (Month 30-Month 36).
Based on the results of WP4, 5, 6, 7 and 8 and the on-going work on the toolbox, ELISAN will develop policy briefs aimed at giving policymakers as well as public authorities key points of action (legislations, financial support).