Multidimensional integrated services to support independent living at home for people with chronic conditions

Background
Name of your initiative: 
Multidimensional integrated services to support independent living at home for people with chronic conditions
Short name (acronym): 
Autonom@Dom
Website title and address: 
Autonom@Dom®
Which organization is submitting this initiative?: 
Isere County Council
Please specify in which regions/provinces: 
FRANCECENTRE-ESTRhône-AlpesIsère
City: 
City of Grenoble
Where is this organization located?: 
France
Please enter the name of the contact person for this initiative: 
Sarah Hustache-Attiyoub
Please enter the email of the contact for this initiative: 
Sarah.hustache-attiyoub@cg38.fr
Part of larger strategy or programme: 
No
If you answered "other", please specify: 
Please provide us with more details of this programme or strategy: 
The status of the initiative: 
On-going
Please give a summary of your initiative (in English): 
Autonom@Dom® aims to combine a broad range of personal and technology services and assistance for people in need of care who want to stay at home. It covers telecare, telehealth and telemedicine, personal and household services and medical assistance available 24/7 through a telephone helpline. Autonom@dom is based on a call-center and an open software platform for service integration, acting as a one-stop shop for demands and needs for health care and social care from different stakeholders (professionals, older people, families, social workers, carers). It is based on the cooperation between health and social care professionals, the private and the public sector and enabled by ICT and data sharing and analysis. Besides the professional coordination centred on the individual need of the person, services will be proposed to different cohorts of users: - Retired people: Support for personal management and empowerment, based on physical activity, cognitive stimulation, nutritional education and social activities. - Seniors at risk of losing their independence: A prevention program plus a fall prevention program and remote surveillance and monitoring of motor and cognitive activity - Patients suffering from chronic diseases (diabetes, heart disease, Alzheimer's disease, epilepsy): The same package for the group above plus integrated care and remote surveillance and monitoring - Patients suffering from cancer: Coordination of health care and social care, scalability of home services, secondary prevention and remote surveillance -A one-stop front office for anyone facing health or social difficulties, or looking for a home service.
The geographical scope: 
Regional
Type of initiative: 
Public
Environment or setting of the initiative: 
Urban
The economic environment or setting of the initiative: 
Moderate
The most important source of funding for your initiative: 
Other
If other, please specify your source of funding: 
What triggered this initiative?: 
* Anticipating population ageing, * Preventing hospital admissions due to interruption in the medical follow-up, * Better answering to people's needs and wills, * Providing solutions to the current situations: saturation of institutionalised care services, lack of financial and human resources.
Objectives
What are the main objectives of your initiative? Choose a maximum of 3 objectives.: 
Housing: increase the number of older people living independentlyCommunity support and health services: increase in client-oriented and -centered made to measure health and social care and services
Please describe any subgoals of your initiative: 
Improve health and self-autonomy of older people, frail people, people suffering from chronic disease or following hospital discharge at home or in home settings. Improve the integration of health and social care at home and foster cross-sector cooperation.
Target group
Does your initiative target people with a specific impairment or disease?: 
How many people have you reached or do you expect to reach with your initiative?: 
1000 - 10.000
Does your initiative target a specific age group?: 
65 - 7980+
Does your initiative target men or women?: 
Irrelevant
Approach
Please indicate what best describes your initiative: 
ImplementationTechnologyResearchInnovation/action/applied
What type of intervention strategy is used in your initiative?: 
Living lab/pilot
Please indicate the Technology Readiness Level (TRL) of your initiative: 
Prototype and implementation: level 7-9
Who executes the initiative: 
Health service contractersPublic authorityHospitalPrimary health care providersGeneral practitionerPrimary health care providersNursePrimary health care providersPhysiotherapistProvider of social service
What is the relevant physical scale of your initiative?: 
Regional levelRoomIn a residential setting
Please indicate how you think your initiative could be scaled up (made to reach more people): 
In order to prepare the implementation of Autonom@Dom, 6 pilots were implemented in 2013 and evaluated (main results, global strengths and weaknesses, difficulties, feedback from the users). This project will start in 2015 and last for two years. The ambition is to scale it up at the national level. This perspective is already addressed by a national committee (CNOSA: National Committee on Guidance for Autonom@Dom).
Please indicate the type of stakeholders concerned with your initiative.: 
Health service contractersPublic authorityHospitalPrimary health care providersGeneral practitionerPrimary health care providersNursePrimary health care providersPhysiotherapistProvider of social service
Please describe how you think your initiative could be transferred to other regions or contexts: 
Isère County is part of a regional project (“territoire de santé numérique”) that will evaluate this new approach in an area including another county (including parts of the Lyon Metropole). This demonstration is lead in a national deployment perspective, under the responsibility of the Ministry of Health and the Regional Health Agency (ARS).
Is your initiative economically sustainable and does it contribute to economic development?: 
The initiative newly started and is not yet mainstreamed, but the pilots has already helped to put forward ideas for how the initiatives could be sustained. This initiative had also external investment: a business model provided sustainability of the new organisation through decompartmentalisation and relocation of funding between health and social care. New management jobs were created to co-ordinate complex situations, and training was provided for formal and informal carers.
If you selected "other" neighbourhood, please specify:: 
Impact & outcome
Will you collect or have you collected outcome data for this initiative?: 
Yes
What do you consider the key success factors of your initiative? If your initiative has not yet started, please indicate what you expect the key success factors to be: 
* Adherence and good feedbacks from both users and professionals involved in the prefigurative pilots, and in the existing organisations integrating health care and social care at small scale (MAIA, IFGG…) * The new approach will rely on/improve existing structures and tools (health and social networks, data sharing tools…) * Global approach * Different stakeholders from social/health public/private industrial/academic sectors involved from the beginning * Business model ensuring sustainability * Co construction with users and professionals * Planed evaluation: Clinical and medico-economic evaluation "from a societal point of view"/Evaluation of acceptability by users and professionals/Evaluation of deployment prospects: organisation, business models, legal framework * Negociated phases with the consortium that allow to find the best way to achieve the final goals * Political support
What do you consider the main barriers to overcome in your initiative? If your initiative has not yet started, please indicate what you expect the main barriers to be.: 
• Risk assessment of in support actions to change • Lack of numeric resort (GSM network?) in rural or mountain area • Many numeric projets, with a difficulty of planning coherence
What instruments will you use/have used to collect data?: 
Other, namely
If you selected "other" instrument to collect data, please specify: 
If yes, how will you/have you collected those data?: 
Will you collect or have collected socio-economic impact data for this initiative?: 
Will or are the collected data in the initiative publicly available?: