Cristina Bescos

Proposals for enhanced health risk assessment and stratification in an integrated care scenario.

Objectives Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario. Settings The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). Participants Responsible teams for regional data management in the five ACT regions. Primary and secondary outcome measures We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction. Results There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment. Conclusions The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. Applicability and impact of the proposals for enhanced clinical risk assessment require prospective evaluation.

Evaluating Care Coordination and Telehealth Services across Europe through the ACT Programme

This paper presents the main concepts and ideas of the research program ACT (Advancing Care Coordination & TeleHealth Deployment). ACT focuses on studying Coordinated Care (CC) and TeleHealth (TH) services for chronically ill patients, such as heart failure, COPD, diabetes, as well as co-morbid patients. The potential of these services to improve quality of care within European healthcare systems can be fully released only when certain barriers are overcome and organizational changes progress. Therefore, the purpose of ACT, as described in this work, is to study in a qualitative and quantitative manner, with a solid and reproducible research methodology, the organizational and structural procedures supporting effective implementation of CC&TH services in the routine management of chronic patients. The consortium will investigate key organizational and structural drivers in 5 European healthcare regions, and eventually produce a toolkit for use across Europe