The project builds upon the preliminary achievements of the B3 Action Group on Integrated Care of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) that first developed the concept of the B3 Maturity Model. Through the activities of the EU Health Programme funded project SCIROCCO, the Model has been further refined and is supported by a validated online self-assessment tool for integrated care. The ambition of the SCIROCCO Exchange project is to maximise the value and impact of the Model and Tool. The purpose of this hub is to facilitate the process of “matching” the needs of the regions with existing evidence on integrated care, good practices, tools and guidelines and thus facilitate the learning and exchange of good practices. The project will deliver improved coding of available evidence on integrated care and make the learning readily available to potential adopters. The project also explores the readiness of local environment for the adoption of integrated care, using the SCIROCCO online self-assessment tool, in order to understand the local needs and the ground for the transition. This will serve as a basis to design a tailored capacity-building approach and personalised assistance to national and regional health and social care authorities. The project will capture the learning from the process of transferability and knowledge transfer in order to inform improvement planning for integrated care. Finally, the project will also be an opportunity to explore the potential expansion of the SCIROCCO Maturity Model and its online self-assessment tool for integrated care to other relevant areas of active and healthy ageing.
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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.
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