Health and social care in Europe are often delivered in an uncoordinated way. The SmartCare project will formalise two care pathways and support their implementation and piloting in ten European regions. The individual pathway steps are described in local care plans which make use of modern ICT tools to allow health and social care professionals to deliver the best possible care to citizens and patients.

A total of 24 regions and their key stakeholders will define a comprehensive set of integration building blocks around the challenges of data-sharing, coordination and communication. Ten regions will then pilot integrated health & social services to combat a range of threats to independent living commonly faced by older people while the other will prepare for early adoption. In a rigorous evaluation approach, the pilot will produce and document much needed evidence on the impact of integrated care, developing a common framework suitable for other regions in Europe. Guidelines and specifications for procuring, organising and implementing the service building blocks will be produced. The organisational and legal ramifications of integrated care will be analysed to support long term sustainability and upscaling of the services.

SmartCare services will provide full support to cooperative delivery of care, integrated with self-care and across organisational silos, including essential coordination tools such as shared data access, care pathway design and execution as well as real time communication support to care teams and multi-organisation access to home platforms. The services build on advanced ICT already deployed in the pilot regions including high penetrations of telecare and telemonitoring home platforms. System integration will be based, whenever possible, on open standards and multivendor interoperability will be strongly encouraged. The common services will allow efficient cooperative care delivery and empower all older people according to their mental faculties to take part in effective management of their health, wellness, and chronic   conditions and maintain their independence despite increasing frailty

Regions involved: Friuli-Venezia Giulia (IT), Carinthia (AT), Baden Württemberg (DE), South Denmark (DK), Tallin (EE), Aragona (ES), Catalonia (ES), Basque Country (ES), Extremadura (ES), Murcia (ES), Valencia (ES), South Karelia (FI), Central Greece (GR), Attica (GR), North-Western Croatia (HR), Veneto (IT), Noord-Brabant (NL), Rotterdam (NL), Uppsala (SE), Amadora (PT), Kraljevo (SR), Northern Ireland (UK) and Scotland (UK).