By our Member Regional Agency for Health and Social Care of Puglia (AReSS)
The TALIsMAn project proposes a new concept of frailty, based on a holistic view of the state of the individual including social, psychological, and functional factors. In TALIsMAn, taking care of frail and chronic patients means making available an ecosystem of integrated digital services that can support a continuity of care model.
The continuity of care model includes: population stratification, enrolment, multidimensional need assessment, personalised care plan, and follow-up management using telemedicine services.
To address these objectives, TALIsMAn enabled the realisation of an enabling technology infrastructure based on the principles of semantic interoperability and an open innovation approach.
By following the concepts arising from the CarePuglia3.0 model, the solution proposed by the project includes:
- The definition of an API ecosystem based on interoperability and application cooperation principles and on standard and open integration profiles (HL7® FHIR®) related to integrated territorial care processes.
- The implementation and integration of value-added solutions and apps for case management, follow-up and remote monitoring and care services.
- A cloud-based deployment.
The TALIsMAn project tested and validated the solution in two trial scenarios. The first scenario focused on proximity medicine, with the validation of methods and solutions for early detection of frailty risks and continuity of care. A second scenario focused on integrated territorial management.
AReSS conducted this second scenario on integrated territorial management in accordance with the objectives of the CarePuglia3.0 regional programme. The aim was to assure chronic patients about appropriate continuity of care, through taking proactive actions associated with patient empowerment processes and secondary and tertiary prevention interventions. The trial involved 167 workers. Health care and administrative staff in the care facilities were trained and weekly reports on purchasing data were collected from 16 healthcare residences in Puglia and nine general practitioners at the Multipurpose Territorial Center Europa in the city of Bari.
The solution was made available to 300 patients either with cancer or rare diseases through general practitioners. It was also given to 1,160 chronic patients and frail older adults through the staff of the health care residences.
The stratification phase was carried out by accessing more than 50,000 positions derived from the Health Information System of the Puglia Region. For all the patients followed, a personalised careplan was established in accordance with their care needs. A follow-up plan was carried out.
What’s in it for EHTEL members
Efficacy of clinical governance, healthcare sustainability, and prospects for a new marketplace based on the open innovation paradigm, are the three indicators of the success of the TALIsMAn project.
TALisMAn provides complementary materials to several aspects of work that interest EHTEL members. These include continuity of care, associated work between health and social care, the linkage between hospitals and care homes, the use of data – especially involving patients, and the ways in which health authorities can develop successful information systems solutions, including through standards and open integration profiles.