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Publisher's version (útgefin grein), Background: Adolescence is crucial period for laying the foundations for healthy development and mental well-being. The increasing prevalence of mental disorders amongst adolescents makes promotion of mental well-being and prevention interventions at schools important. UPRIGHT (Universal Preventive Resilience Intervention Globally implemented in schools to improve and promote mental Health for Teenagers) is designed as a whole school approach (school community, students and families) to promote a culture of mental well-being and prevent mental disorders by enhancing resilience capacities. The present article aims at describing the rationale, conceptual framework, as well as methodology of implementation and evaluation of the UPRIGHT intervention. Methods: UPRIGHT project is a research and innovation project funded by the European Union's Horizon 2020 Research and Innovation programme under grant agreement No. 754919 (Duration: 48 months). The theoretical framework has been developed by an innovative and multidisciplinary approach using a co-creation process inside the UPRIGHT Consortium (involving seven institutions from Spain, Italy, Poland, Norway, Denmark, and Iceland). Resulted is the UPRIGHT programme with 18 skills related to 4 components: Mindfulness, Coping, Efficacy and Social and Emotional Learning. Among the five Pan-European regions, 34 schools have been currently involved (17 control; 17 intervention) and around 6000 adolescents and their families are foreseen to participate along a 3-year period of evaluation. Effectiveness of the intervention will be evaluated as a randomized controlled trial including quantitative and qualitative analysis in the five Pan-European regions representative of the cultural and socioeconomic diversity. The cost-effectiveness assessment will be performed by simulation modelling methods. Discussion: We expect a short- to medium-term improvement of mental well-being in adolescents by enhancing resilience capacities. The study may provide robust evidence on intrapersonal, familiar and social environmental resilience factors promoting positive mental well-being. Trial registration: ClinicalTrials.gov Identifier: NCT03951376. Registered 15 May 2019., Horizon 2020 Framework Programme. The authors wish to thank all adolescents, their families and professionals from educational centres involved in the UPRIGHT programme. UPRIGHT is a research and innovation project funded by the European Union’s Horizon 2020 Research and Innovation programme under grant agreement No. 754919. The grant agreement (protocol) has undergone peer-review by the European Commission reviewers (governmental and major funding organism) before getting approval.

Background Older patients with multimorbidity have complex health and social care needs, associated with elevated use of health care resources. The aim of this study is to evaluate the impact of CareWell integrated care model for older patients with multimorbidity in the Basque Country. Methods The CareWell program for older patients with multimorbidity, based on the coordination between health providers, home-based care and patient empowerment, supported by information and communication technology tools. The program was deployed in four healthcare areas in the Basque Country. The control group was formed by two organizations in which the program had not been deployed and regular care procedures were applied. Participants, older patients (aged ≥65) with two or more chronic conditions (at least one being chronic obstructive pulmonary disease, chronic heart failure, or diabetes mellitus), categorized as complex according to a risk stratification algorithm, were followed up to 12 months. The impact of the program on the use of health resources, clinical effectiveness, and satisfaction was evaluated using a mixed-method approach. Semi-structured interviews were performed to assess satisfaction with the newly deployed model and mixed regression models to measure the effect of the intervention throughout the follow-up period. Results Two hundred patients were recruited (101 intervention and 99 control), mostly males (63%) with a mean age of 79 years and age-adjusted Charlson Comorbidity Index of 9.7 on average. Relevant differences between the groups were observed for all dimensions. In the intervention group, the number of hospitalizations and visits to emergency centers was reduced, and the number of primary care contacts increased. Clinical changes were also observed, such as a decrease in the body mass index and blood glucose levels. The satisfaction level was high for all stakeholders. Conclusion The implementation of CareWell integrated care model changed the profile of health resource utilization, strengthening the key role of primary care and reducing the number of emergency visits and hospitalizations. The satisfaction with this model of care was high. Trial registration ClinicalTrials.gov, NCT03042039 . Registered 3 February 2017 - Retrospectively registered.

Objective The objective of this work was to assess the effectiveness of a population-level patient-centered intervention for multimorbid patients based on risk stratification for case finding in 2014 compared with the baseline scenario in 2012. Data source Clinical and administrative databases. Study design This was an observational cohort study with an intervention group and a historical control group. A propensity score by a genetic matching approach was used to minimize bias. Generalized linear models were used to analyze relationships among variables. Data collection We included all eligible patients at the beginning of the year and followed them until death or until the follow-up period concluded (end of the year). The control group (2012) totaled 3558 patients, and 4225 patients were in the intervention group (2014). Principal finding A patient-centered strategy based on risk stratification for case finding and the implementation of an integrated program based on new professional roles and an extensive infrastructure of information and communication technologies avoided 9 percent (OR: 0.91, CI: 0.86-0.96) of hospitalizations. However, this effect was not found in nonprioritized groups whose probability of hospitalization increased (OR: 1.19, CI = 1.09-1.30). Conclusions In a before-and-after analysis using propensity score matching, a comprehensive, patient-centered, integrated care intervention was associated with a lower risk of hospital admission among prioritized patients, but not among patients who were not prioritized to receive the intervention.

Purpose To ensure that more people will benefit from integrated care initiatives, scaling-up of successful initiatives is the way forward. However, new challenges present themselves as knowledge on how to achieve successful large-scale implementation is scarce. The EU-funded project SCIROCCO uses a step-based scaling-up strategy to explore what to scale-up, and how to scale-up integrated care initiatives by matching the complementary strengths and weaknesses of five European regions involved in integrated care. The purpose of this paper is to describe a multi-method evaluation protocol designed to understand what factors influence the implementation of the SCIROCCO strategy to support the scaling-up of integrated care. Design/methodology/approach The first part of the protocol focuses on the assessment of the implementation fidelity of the SCIROCCO step-based strategy. The objective is to gain insight in whether the step-based strategy is implemented as it was designed to explore what works and does not work when implementing the scaling-up strategy. The second part concerns a realist evaluation to examine what it is about the SCIROCCO’s strategy that works for whom, why, how and in which circumstances when scaling-up integrated care. Findings The intended study will provide valuable information on the implementation of the scaling-up strategy which will help to explain for what specific reasons the implementation succeeds and will facilitate further improvement of project outcomes. Originality/value The expected insights could be useful to guide the development, implementation and evaluation of future scaling-up strategies to advance the change towards more sustainable health and care systems.

Introduction/context : Depression is one of the most frequent mental health diseases worldwide, with approximately 350 million of individuals affected. Antidepressants are still the mainstay of treatment for depression in healthcare settings. In the Basque Country, about 400.000 people suffer from depression; 10% of them with mild or moderate symptoms. cCBT has proven to be effective to fight depression, enabling the patient to change destructive patterns. This type of cCBT can be self-administrated at any time and place; this is why it contributes to improve accessibility to treatment. Also, it enables the delivery of care at the natural environment, minimizing the negative effect of mental health stigma, and contributing to the acceptance of the one's own condition. Description/aim : The Basque Country, within the European project Mastermind, has deployed a Computerized Cognitive Behavioral Therapy (cCBT) service. The Mastermind project started in March 2014 and finishes in Febrary 2017. During the implementation phase, barriers and facilitators related to both clinical and organizational areas have been identified and analyzed. The cCBT platform enables a two-way patient-professional communication, a close patient´s follow-up, while providing the patient with tools to manage its own condition and prevent future episodes. Methods : The practice being implemented in the Basque Country comprises three main work areas: 1. Develop a cCBT platform, called “Supera tu depresion” together with other 3 Spanish partners of the project, taking into account the needs for patient-professional interaction and fluid communication, integration within information systems and therapeutic content that nurtures the platform. The piloting in the Basque Country started in January 2016 and finishes in Febrary 2017, due to the finalisation of the project. 2. Deploy a protocol for comprehensive care that includes key professionals (primary care, mental health and emergency) adapted to the context of the Basque Country. 3. Put into practice an integrated care intervention targeting individuals over 18 years old, diagnosed of low or mid depression. 4. Pre-post assessment of quantitative and qualitative aspects (by focus groups to clinicians and semi structured interviews to managers) according to the MAST model. Results/discussion/lessons learned : The results are to be measured according to the MAST model in terms of health problems, application features, safety, clinical effectiveness, patient and professional perspective and economic, organizational, socio-cultural, ethical and legal aspects. The following data is being analyzed in the Basque Country and the results will be published in the first quarter of 2017. Out of the 182 patients took part in the project, 23 have finalized the therapy and 89 are drop outs. Nowadays, 70 patients still continue in the therapy, and their data will be analyzed after the finalization of the project (Febrary 2017). Although the overall quantitative analysis is ongoing, some conclusions can be highlighted from the qualitative perspective: The patients who complete the therapy are very satisfied with it, although the technical difficulties and lack of time of the professionals have been important barriers. The simplicity of the software and its robustness has been identified as critical success factors, both for patients and professionals. This project will raise awareness about the key issues underpinning online cCBT integration within regular care, generating the knowledge and expertise needed for the extension of this type of care. Transferability : The inclusion of the therapy in the day-to-day practice is being raised in the Basque public Health Provider, Osakidetza. The final decision will depend on the results of the analysis that are being performed during the last months of 2016. If positive, the possibility to provide the cCBT service using existing corporative tools will be assessed.

Introduction : Population aging and the increased number of chronic diseases push the healthcare systems to design and implement new strategies to improve the quality of services. These strategies require investment in ICT tools, promotion of patient empowerment in the management of their disease and a better integration of health and social care services. CareWell project focuses on the delivery of integrated healthcare to frail elderly patients who have complex health and social care needs, are at high risk of hospital or care home admission and require a range of high-level interventions due to their frailty and multiple chronic diseases. Carewell aims at deploying services supported by ICT which enhance the coordination and communication of healthcare professionals, improves patient´s remote follow up and boosts patient (and caregiver) empowerment. The aim of the project is the identification of the impact of implementing an integrated care model for frail elderly patients, according to quality of care, efficiency and both patients´ and professionals´ satisfaction. Short description of the intervention : Following the inclusion criteria and based on the population stratification dataset, the GP identifies potential candidates. Then, the GP proceeds to schedule a consultation with the patient to perform a comprehensive assessment, define the therapeutic plan and provide patient with educational material in order increase his/her self-management capability. Then, the GP nurse schedules a face-to-face follow-up plan depending on the patient's needs. During this face-to-face consultation, the GP nurse analyses patient's therapeutic plan and his/her adherence to treatment, reinforces patient's self-management capacity through an educational plan, revises lab tests and performs medical examinations. If no worsening symptoms are detected, the patient is reviewed approximately every three months. However, if any instability sign is identified, the patient is referred to the GP in order to reassess his/her clinical situation. If the patient can benefit from home care, a variety of resources can be activated. If the patient cannot be treated at home, or his/her health status continues to worsen, the patient will be admitted to hospital. During the hospitalisation, the reference internist is in charge of assessing the patient's clinical situation, defining corresponding treatment, managing medical interventions and coordinating specialists. Once the patient is stable, the reference internist will consider if the patient requires additional interventions such as home-hospitalisation, admission to a sub-acute hospital, social care, or special coordination with primary care. At hospital discharge, the reference internist writes the discharge letter and contacts the GP to ensure continuity of care. In addition, the hospital nurse draws up the patient's follow-up plan, and schedules a face-to-face appointment between the patient and the GP nurse. The visit with the GP nurse is the starting point of the integrated care pathway, from where the patient can be referred to periodic follow-up consultations or to hospital, depending on his/her health status. Key findings: The definition of the care pathway supported by ICTs has been deeply discussed in an inter-organizational and multidisciplinary work group (managers, clinicians nursing of primary care and hospitals, eHealth Centre, Department of Information Systems, Department of Healthcare and Kronikgune), ensuring that all stakeholders´ opinions and needs are considered. 200 patients (100 intervention group and 100 control group) have been recruited and the services aforementioned are fully operational. At this moment the enrolment data is being collected and the baseline analysis (quantitative and qualitative indicators) will be performed during December. In addition, predictive modeling approach will be carried out to estimate the use of resources in mid- and long-term after the new service deployment. Highlights and conclusions : Intervention perspective: - Need of a clear methodology to design the intervention (analysis of current model, detection of improvement areas, prioritize actions and define the new care pathway) - Need of resource re-organization and definition of new roles to improve coordination between different healthcare levels (primary and secondary care). - Primary Care is responsible for proactive control of the patients. - Patient and informal caregiver empowerment leaded by nursing is essential. - Technology is crucial to facilitate coordination between healthcare professionals. Implementation perspective: - Need to align the objectives of the project with the strategic plan of the central organization so the deployment of the service becomes a priority. - Importance of reach consensus among all stakeholders in the definition of the care pathways in order to consider different perspectives (managerial, technical and methodological competences). - Ensure the service is adaptable and flexible enough to be adopted in new contexts. - Distributed leadership is crucial from the implementation process perspective (clinical, managerial and methodological) - Need to share midterm results and collect feedback from front-line professionals to detect improvement areas

Introduction : Around 50% of those suffering a depression do not receive treatment and this is due to barriers such as lack of resources for mental health care or stigma related to mental disorders. Research shows that some of these barriers can be successfully overcome with ICT-based solutions among which Computerized Cognitive Behavioral Therapy (cCBT) has proven to be an effective and cost effective treatment for depression. Unfortunately the use of these ICT is still anecdotal in most regions and little is known about the potential health and economic impact of its generalization. Mastermind project is an EC co-funded project involving 23 partners of 11 European countries. Mastermind pretends to up-scale cCBT based interventions across distinct European regions and study the barriers and facilitators of the implementation process. In addition, a comprehensive evaluation process has been set up to study quantitative and qualitative indicators framed into seven domains: health problem, safety, clinical effectiveness, organizational aspects, economic aspects, patients perspective, socio/legal/ethical aspects. In the Basque Country 300 patients will participate in the cCBT intervention. Short description of the intervention : The integrated care based intervention deployed in the Basque Country aims to give a major role to the primary care professionals in the provision of care for patients with depression. The GP and GP practice nurse are responsible for identifying and recruiting patient fulfilling the inclusion criteria defined (>18 years with mild or moderate depression diagnosed by the Patient Health Questionnaire-9). Once the patient accepts to participate in the project, the primary care team trains him/her in the use of the cCBT programme and provides him/her with the required username and password. During the online therapy, the patient has to fill different health related questionnaires (PHQ-9, BDI, Euroqol and MANSA-2) and go through 8 educational modules. Each module contains three sections: explanatory text, summary presentation and a video. The patient is supposed to read the text, revise the presentation and listen to the video in order to internalize the content of the session. Afterwards, the patient fills some specific exercises that are reviewed by the GP. During the online therapy, the primary care team are in charge of monitoring the progress of the patient and are supported by the nursing of the eHealth Centre, who work 24x7, in several tasks: phone calls to reinforce the adherence to the treatment, follow-up calls and activation of health resources depending on the final scores of the questionnaires (schedule an appointment in the GP office or specialist, activation of the ambulance). During the cCBT, the specialists (psychiatrists and psychologists) support the GPs in any decision-making when necessary. To do so, the GP solves clinical doubts via intercolsultations (messages via the EHR) or or via videoconference. Key findings : - The cCT programme has been collaboratively developed by the 4 Spanish regions within the project (Aragon, Galicia, Badalona and Basque Country) based on the existing scientific evidence. The programme has been adapted to their local requirements (language, culture and health care characteristics). - The four Spanish regions are deploying a similar organizational model in order to demonstrate the validity of both the online programme and the integrated care intervention. - Primary care professionals have to manage patients with mild and moderate depression, limiting the participation of the specialists to the most complex cases and severe depression. By this way, the waiting lists will be reduced in the mental health centers and primary care professionals are provided with a effective tool to improve their decision making. - Intense dissemination and sensitization efforts have been done to maximize the interest of health professionals and patients in the use of ICT resources as part of depression treatment. Highlights: (lessons learned) - Definition of the cCBT programme based on the requirements of both patient and professionals profile. - Need to reinforce the knowledge of primary care professionals in the clinicnal management of the depression. - Integration between distinct healthcare professionals (GP, GP practice nurse, specialists and eHealth Centre) is crucial to ensure an integrated care for patients with depression. - The duration of the online therapy has to be limited (eg. 12 weeks) in order ensure the engagement of the patient and guarantee the effectiveness of the therapy. Conclusions : The cCBT will be deployed in distinct regions trying to identify barriers and facilitators of the implementation process. The knowledge generated will be of paramount importance for future extensions of this type of care in a safe, efficient and effective way.

Objectives To develop a framework for the management of complex health care interventions within the Deming continuous improvement cycle and to test the framework in the case of an integrated intervention for multimorbid patients in the Basque Country within the CareWell project. Methods Statistical analysis alone, although necessary, may not always represent the practical significance of the intervention. Thus, to ascertain the true economic impact of the intervention, the statistical results can be integrated into the budget impact analysis. The intervention of the case study consisted of a comprehensive approach that integrated new provider roles and new technological infrastructure for multimorbid patients, with the aim of reducing patient decompensations by 10% over 5 years. The study period was 2012 to 2020. Results Given the aging of the general population, the conventional scenario predicts an increase of 21% in the health care budget for care of multimorbid patients during the study period. With a successful intervention, this figure should drop to 18%. The statistical analysis, however, showed no significant differences in costs either in primary care or in hospital care between 2012 and 2014. The real costs in 2014 were by far closer to those in the conventional scenario than to the reductions expected in the objective scenario. The present implementation should be reappraised, because the present expenditure did not move closer to the objective budget. Conclusions This work demonstrates the capacity of budget impact analysis to enhance the implementation of complex interventions. Its integration in the context of the continuous improvement cycle is transferable to other contexts in which implementation depth and time are important.

Published version also available at http://dx.doi.org/10.1016/j.invent.2015.10.002 Background: Depressive disorder is a major societal challenge. Despite the availability of clinically and costeffective treatments including Internet interventions, the number of patients receiving treatment is limited. Evidence-based Internet interventions promise wide availability and high efficiency of treatments. However, these interventions often do not enter routine mental healthcare delivery at a large scale. The MasterMind project aims to provide insight into the factors that promote or hinder the uptake and implementation of evidence-based Internet interventions by mental healthcare practice. Internet-based Cognitive Behaviour Therapy (iCBT) and videoconferencing facilitating collaborative care (ccVC) will be implemented in routine mental healthcare. The services will be offered to 5230 depressed adults in 15 European regions. The current paper describes the evaluation protocol for this large-scale implementation project. Design: Current summative evaluation study follows a naturalistic one-group pretest–posttest design and assesses three distinct stakeholders: patients, mental healthcare professionals, and mental healthcare organisations. The Model for Assessment of Telemedicine applications (MAST) will be employed to structure the implementation and evaluation study. The primary focal points of interest are reach, clinical effect, acceptability,appropriateness, implementation costs, and sustainability of the interventions in practice. Mixed-methods are used to provide an understanding of what (quantitative) the implementation projects have achieved and their meaning to various stakeholders (qualitative). Discussion: The use of Internet interventions in routine practice is limited. MasterMind attempts to bridge the gap between routine practice and effectiveness research by evaluating the implementation of evidence-based Internet interventions for depressive disorders in routine mental healthcare settings in Europe.

Introduction: Congestive Heart Failure (CHF) is a complex syndrome characterized by the inability of the heart to expel sufficient amount of blood needed for metabolic requirements of different organs. As a result, the typical symptoms affecting patient with CHF are dyspnea and fatigue at rest or with reduced physical effort, and loss of appetite, which sometimes appear gradually over days or weeks. Epidemiological studies indicate that the prevalence of CHF is considerably high affecting 10% of the population older than 70 years old. Due to the population ageing and the increased survival to acute cardiac diseases, CHF is becoming more common, representing a public health problem. In consequence, it will become increasingly difficult to maintain the quality of care of patient suffering from CHF. In this context, home telemonitoring appears to be a promising alternative to allow healthcare professionals to follow up patient s health status more closely and then facilitating early detection of worsening symptoms. However, the effectiveness of these interventions in real conditions has not yet been sufficiently tested, since the implementation of telemonitoring services is considerably complex. Frequently telemonitoring studies do not overcome the pilot phase and do not reach the expected success when it comes to scale and place the intervention in routine practice. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117013 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Aim: Define and implement cost-effective and sustainable telemonitoring services for patients with CHF within an integrated care model where each actor performs the task more suited to his/her position in the value chain. Timeline: 300 patients will be recruited from May 2014 to January 2015 and each patient will be followed up during 12 months. Methodology: Definition of crucial aspects of the telemonitoring intervention has been deeply discussed in an inter-organizational and multidisciplinary work group, reaching consensus on how to implement the services within an integrated organizational model. The working group is composed by: managers (primary care and hospitals), cardiologists, general practitioners, nursing (from primary care, hospital and eHealth Center), Telecare Centre’s director and staff from the Department of information systems. The indicators that will be measured consider health outcomes, patient s quality of life, economic and organizational aspects, patient s perception, and ethical-legal-cultural aspects. Short description of practice change implemented: The patient who meets the inclusion criteria and signs the informed consent will be enrolled in the intervention. The technical provider will be responsible for installing devices for the measurement of the heart rate, blood pressure, pulseoxymetry and weight at patient's home within a week after recruitment. In addition, a personal alarm device for 24/7 real-time emergency detection will be installed. The patient will be trained in using the telemonitoring and telecare devices. Following the clinician's prescription, the patient will routinely transmit his/her parameters at least once per week. The telemonitoring devices collect and send the data wirelessly to the gateway located at his/her home. The gateway device transmits the data collected by the patient to the alarm management system of the _Telecare Centre_. The operator of the Telecare Centre checks the data sent by the patient and activates the predefined protocol agreed by a group of professionals, including clinicians, general practitioners, nurses, general directors and representatives of the social area. When clinical parameters are out of range, the operator first verifies the alarm situation by a phone call to the patient. If the alarm is validated, the operator triggers the protocol depending on the severity of the situation. The operator contacts the _eHealth Centre_ composed of nurses; they then solve the alarm on their own, notify the _general practitione_ or the _specialist_, or activate _Emergency Department_. If the patient uses the 24/7 real-time alarm device provided, the Telecare Centre's operator can contact the Emergency Department and/or social services. In addition, the Telecare Centre also solves any technical problems arising in the use of devices. Conclusions and lessons learned: The conclusions reached at this point of the project are: Need of resource re-organization and definition of new roles. The organizational model using telemonitoring services model has to be well adapted to the routine practice. Complete telemonitoring service has to be provided (device installation, maintenance and user training) Need of both administrative management and guarantee of good quality of telemonitored data (avoiding false alarms). Patient empowerment leaded by nursing is essential. Primary Care is responsible for proactive control of the patients Technology is crucial to facilitate both coordinated management of all processes and communication between healthcare professionals. Healthcare professionals do not have to deal with different technological platforms; they should work on the Electronic Health Record of each patient.

Introduction: Bipolar disorder is a disease that causes changes in the regulation of mood, varies from deep depression to more uncontrolled euphoria without external events that justify these variations. Bipolar dissorder affects 2-5% of the population, with similar prevalence among men and women without differences of race or social class, and usually arise between 20-30 years old. The cause are varied and can be genetic, and therefore inheritable, but enviromental factors (stress, drug use...) that make emerge the disorder are required. Short description of practice change implemented: The usual treatment is based not only in drug therapy but also in educational programs such as psycho-education programs to provide information to patients and family about the disease and negative habits, help to know the symptoms of destabilization and establishing routines, teach to cope with the stress and the importance of taking proper medication. However, the therapies on line are becoming more frequent with the technological advances. These therapies offers advantages compared to the usual treatment as: facilitate access to therapy (not displacement and possibility to adjust schedules), the anonymity is guarantee... A new approach for online treatment has been development, the Bipolar Patient Treatment Manager (BPTM) solution which provides telecare service based on advanced communication channels to treat, monitor and support people with mental disorders and their relatives. A rigorous analysis of various online treatments has been done in order to design an application which 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117110– http://www.ijic.org/ satisfies all the relevant features: appropiate educational programs, enviroment friendliness, multichannel interaction, security in the exchange of information... Targeted population and stakeholders: The targeted population for the BPTM solution are patients with bipolar disorder, their carers and the professionals involved in their care and treatment (primary and specialized level). Timeline: A clinical trial will performed in May, 2015 with a duration of three months. The clinical trial will consist on the comparation of two patient and carer groups (intervention and control): 30 patients and their carers using the BPTM solution (intervention group) and 30 patients and their carers with usual treatment (control group). The profesional teams involve agents from primary and specialized care of the Basque Health System (Osakidetza). Highlights: (innovation, impact and outcomes) The designed application (BPTM) has been development and consists on the following modules: psycoeducation, psycotherapy, health state monitoring, drug treatment adherence. The solution is being developed to allow secure multi-channel interaction between patients and health care professionals, to ensure safely information exchanged which allow to integrate the clinical relevant information within the existing electronic health record by interoperating with existing infrastructures trough standards. Conclusions: The BPTM solution will offer ways to learn about how to manage the disease and how to identify symptoms and risk or unstable clinical situations; means to register, share, and access relevant quantitative and qualitative status information, drugs intake, and potentially unwanted side effects; feedback relevant for psychotherapy (i.e. information to the patient about the evolution of his/her disease, motivational messages, and comments of his/her therapist). Discussions: The expected results of the online treatment are basically focused on improving health outcomes and efficiency, increasing the population treated and the adhesion to the treatment, avoiding readmissions and optimizing the resources used. The cost-effectiveness and the transferibility of the application will be evaluated Lessons learned: Some our lessons learned in the development of the online application are related to the need of adaptation of the application to the user requierement. These user requirements involved several areas as the content in the application depending on targeted population, an active and attractive application with an easy handling in order to assure the patients treatment adherance, but also confidentiality, security, privacity and tracebility to be sure that the application has been used by the adequate person.

Introduction: Depression is one of the most frequent mental health diseases worldwide, with aproximately 350 million of individuals affected. Nevertheless, over 50% of them do not receive an adequate treatment. Lack of resources and mental health illness' stigma are among the barriers to it. On the other hand, lack of accessibility and mental health services' waiting lists contribute to this situation. Computerised Cognitive Behavioural Therapy (cCBT) has proven to be effective to fight depression, enabling the patient to change destructive patterns. This type of cCBT can be selfadministrated at any time and place; this is why it contributes to improve accessibility to treatment. Also, it enables the delivery of care at the natural environment, minimizing the negative effect of mental health stigma, and contributing to the acceptance of the one's own condition. The main objective of this project is to deploy a cCBT solution, within an integrated care intervention, as well as to identify and analyze the barriers and facilitators of this process, both in the clinical and organizational fields. Short description of practice change implemented: The practice being implemented comprises two main work areas: 1. Development of a cCBT platform, taking into account the needs for patient-professional interaction and fluid communication, integration within information systems and therapeutic content that nurtures the platform. The integration of the plataform will be finished in January 2015. 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117109– http://www.ijic.org/ 2. Put into practice an integrated care intervention targeting 300 individuals over the age of 18, diagnosed of depression according to DSM IV, and recruited in mental health care centres, primary care centres and hospitals. This intervention will begin the September 2015. The patients will be treated for 12 months and their status will be evaluated at the baseline, in the middle of the treatment, at the end of the treatment and three months after the end of the intervention. The assessment of the professionals and organizations involved will be carried out at the end of the treatment. Highlights: The cCBT platform enables a two-way patient-professional communication. On the other hand, the architecture of the platform enables a close follow-up, while providing the patient with tools to manage its own condition and prevent future episodes. Regarding the deployment of the intervention, scalability of the model to the health system, transferability to other health systems, decrease of adverse events and health outcomes, costeffectiveness, inequities and waiting lists evolution will be measured. For this, the results will be analyzed at three levels: patients (control group and intervention group), professionals (primary care and mental health) and health services organizations. Conclusions: This project is expected to raise awareness about the key issues underpinning online cCBT integration within regular care, generating the knowledge and expertise needed for the extension of this type of care in a safe, efficient and effective way.

An introduction: (comprising context and problem statement) The high prevalence of patients with complex needs is an increasingly worrying reality in health systems. The most characteristic features of the current healthcare model are the fragmentation of care levels, the lack of coordination, integration and continuity in patient care, leading to problems of inappropriate use of human and economic resources and health services. The problem requires a coordinated response comprising all stakeholders involved. Short description of practice change implemented: The European Carewell project http://www.carewell-project.eu/home.html aims the design and implementation of new organizational models of integrated cost-effective care, addressing multimorbid patients, in order to improve care and healthcare through: 1) the coordination and communication among health professionals, and 2) the patient-centered care based on empowerment of the patient (and their caregiver) and the monitoring of their health status. The project uses ICTs as enablers for the implementation of such interventions. Aim and theory of change: The main objective of Carewell is the design, implementation and evaluation of the impact of an integrated healthcare model for multimorbid patients, in terms of quality of care, efficiency and satisfaction of professionals and patients Targeted population and stakeholders: The target population was elderly (≥ 65) patients having at least two of the chronic diseases included in the Charlson comorbidity index and being one of them CHF, EPOC or diabetes mellitus. In the Basque Country a population of around 6200 patients have benefited from the new integrated care pathway whereas only 200 patients (104 intervention and 100 controls) have been included in the evaluation. These patients have been followed up for a minimum of 9 months. There are 13 integrated care organizations (ICOs, primary and secondary care) in the Basque Country. 6 out of the existing 13 have been involved in the project. A multi-disciplinary, collaborative and inter-organizational team, which consisted in 130 health professionals and 58 social workers from distinct ICOs, was created to define and deploy the new care pathway. Timeline: The project started in February 2014 and phases completed are: - Definition of the new integrated care pathway: February-December 2014 - Preparation of the piloting (professional engagement and training): January-April 2015 - Piloting: May 2015-September 2016 - Evaluation: October-December 2016 Highlights: (innovation, Impact and outcomes) Innovation: A new organization model for the care of multimorbid patients has been defined,developed and deployed. Several elements have been identified as key factors: integrated care pathways agreed by all stakeholders, decision support tools, ICT services, training of professionals, development of an structured empowerment program for patients and caregivers (Kronik-ON) and a new mathematical model to predic sue of resources in mid-long term ("Predictive Modeling"). Impact: In the Basque Country the new organizational model has had an impact on the provision of services to multimorbid patients. Through the prevention and promotion of health, as well as the empowerment of patients, it has promoted a transition from specialized and hospital care to primary care. Outcomes: Clinical effectiveness, economic analysis and the patient's and professionals´ perspectives have been assessed by quantitative and qualitative approaches. Satisfaction of both professionals and patients/caregivers has been demonstrated, whereas the profile of the use of services has moved from secondary care to primary. In fact, then number of hospitalizations and ED visits has decreased and the GP contacts have augmented. Comments on sustainability: The intervention in the Basque Country has used the human and technological resources currently available in Osakidetza (Basque Health Public System), which favors and facilitates any subsequent deployment. Predictive analysis has confirmed that intervention is cost effective. Comments on transferability: The results of the evaluation of the new organizational model have been positive, which has led to its imminent extension to other ICOs of Osakidetza. Conclusions (comprising key findings) and lessons learned: -A detailed methodology for the design of the intervention is crucial -Multidisciplinary teams should represent all stakeholders in order to consider their perspective in the definition of new care pathways. -New pathways must be integrated into the daily practice. -the service must be flexible to be adopted in new contexts -New roles are necessary which requires reorganization of tasks -Training of professionals is crucial to promote the development of new skills -Technology is essential for facilitating coordination among health professionals -Involvement of top managers of the organizations enhances the engagement of healthcare professionals, favoring the implementation of new procedures -Primary Care is responsible for proactive control of the patients -Nursing role is essential in the empowerment of the patient/caregiver Discussions: It is fundamental to align the project objectives with the strategic plan of the central organization to ensure that the deployment of the intervention is a priority. However, top-down support is not enough, meso-level managers and front-line professionals have to believe in the project, so both interests converge. Continuous improvement methodologies are of great relevance identify weaknesses in a regular basis and apply new solutions. To do so, it is mandatory to establish a consolidate monitoring and assessment procedures.

Introduction : The prevalence of congestive heart failure is considerably high affecting 10% of the population older than 70 years old. Due to the population ageing and the increased survival to acute cardiac diseases, CHF is becoming more common, representing a public health problem. In consequence, it will become increasingly difficult to maintain the quality of care of patient suffering from CHF. In this context, home telemonitoring appears to be a promising alternative to allow healthcare professionals to follow up patient´s health status more closely and then facilitating early detection of worsening symptoms. However, the effectiveness of these interventions in real conditions has not yet been sufficiently tested, since the implementation of telemonitoring services is considerably complex. Frequently telemonitoring studies do not overcome the pilot phase and do not reach the expected success when it comes to scale and place the intervention in routine practice. The aim of the project is to define and up-scale cost-effective and sustainable telemonitoring services for patients with CHF. Definition of the organizational model and the ICT infrastructure of the telemonitoring intervention have been deeply discussed in an inter-organizational and multidisciplinary work group, reaching consensus on how to implement the services within an integrated organizational model. Both the care pathway and the technological solution have been defined in order to design a sustainable service. On one hand, the organizational model is adaptable and flexible enough to be tailored to new contexts allowing new organizations to incorporate the service into their routine practice. On the other hand, a huge effort has been done to integrate distinct technological platforms which permit that the telemonitoring data flow from patient´s home to the EHR. Short description of practice change implemented: The patient who meets the inclusion criteria and signs the informed consent is enrolled in the intervention. The technical provider is responsible for installing devices for the measurement of the heart rate, blood pressure, pulse-oxymetry and weight at patient's home within a week after recruitment. In addition, a personal alarm device for 24/7 real-time emergency detection is installed. The patient is trained in using the telemonitoring and telecare devices. Following the clinician's prescription, the patient will routinely transmit his/her parameters at least once per week. The telemonitoring devices collect and send the data wirelessly to the gateway located at his/her home. The gateway device transmits the data collected by the patient to the alarm management system of the Telecare Centre. The operator of the Telecare Centre checks the data sent by the patient and activates the predefined protocol agreed by a group of professionals, including clinicians, general practitioners, nurses, general directors and representatives of the social area. When clinical parameters are out of range, the operator first verifies the alarm situation by a phone call to the patient. If the alarm is validated, the operator triggers the protocol depending on the severity of the situation. The operator contacts the eHealth Centre composed of nurses; they then solve the alarm on their own, notify the general practitioner or the specialist, or activate Emergency Department. If the patient uses the 24/7 real-time alarm device provided, the Telecare Centre's operator can contact the Emergency Department and/or social services. In addition, the Telecare Centre also solves any technical problems arising in the use of devices. Key findings: 150 patients have been recruited from May 2014 to June 2015 and each patient has been followed up to 12 months. Preliminary results: 42.25% alarms are technical The remaining 57.75%: - 79.7% do not activate alarm - 20.3% out of range (54.8% false positive, 30.3% true alarms, 14.7% not confirmed) Healthcare activities upon alarms: - 84,1%: solved by eHealth Centre - 5,1%: solved by primary care - 10,7%: solved in secondary care High patient and caregiver satisfaction Highlights : - The organizational model using telemonitoring services model has to be well adapted to the routine practice. - Complete telemonitoring service required (device installation, maintenance and user training) - Need of both administrative management and guarantee of good quality of telemonitored data (avoiding false alarms). - Primary Care is responsible for proactive control of the patients - Distributed leadership is crucial from the implementation process perspective (clinical, managerial and methodological) - Need to share midterm results and collect feedback from front-line professionals to detect improvement areas Conclusions : We have seen that project objectives have to be completely aligned with the central organization´s strategic plan to ensure the sustainability of the services. Using corporative technological platforms and existing resource re-organization also contribute to the maintenance of the service in long term.

Introduction : One of the distinctive characteristics of frail elder patients with comorbidities is the complexity of the health and social needs they present as well as their vulnerability and high risk to develop dependence and high services consumption. The provision of healthcare to these individuals should be able to respond to their complex needs in order to improve their health status and to prevent avoidable resource consumption and suffering. Integrated care may be an adequate strategy to achieve this goal. The CareWell Project, co-funded by the European Commission, is aimed to assess the impact of new organisational models to provide ICT supported integrated healthcare (IHC) to frail elderly patients with comorbidities. The overall aim of the evaluation carried out in CareWell is to assess the impact of the implementation of ICT supported integrated healthcare. Evaluation will be conducted using the MAST multi-dimensional evaluation methodology adapted to the needs of CareWell project, focusing on integrated healthcare. MAST includes assessment of the outcomes divided into the following seven domains: 1) Health problem and characteristics of the application; 2) Safety; 3) Clinical effectiveness; 4) Patient perspectives; 5) Economic aspects; 6) Organisational aspects; and 7) Socio-cultural, ethical and legal aspects . This communication will be focused on the baseline assessment of the recruited subjects. Methods : CareWell is a quasi-experimental study with a control group, targeting community-dwelling frail subjects suffering from one of the following disease: chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) (both insulin-dependent and noninsulin-dependent) or chronic heart failure (CHF) as well as one other comorbidity. Subjects in the intervention group have received the IHC and the control group, the usual care provided by their health system. The project is being developed in six pilot sites through Europe. All pilot sites have conducted a baseline assessment of the study population prior to the deployment of the new organisational model, which will serve as the basis for comparison (usual care), and again at the end of the follow-up, one year after the deployment (new care). Descriptive analysis have been performed for each variable included in this study using mean and standard deviation for quantitative variables, and frequencies and percentages for categorical variables. Variables collected in the basal assessment include socio-demographic variables (age, sex, education level, occupation, income); health related habits (alcohol and tobacco consumption, physical activity); health status (comorbidities, functionality status using Barthel Index, mental health status using Geriatric Depression Scale); and self-perceived experience with care provision measured by PIRU Questionnaire. Results : Overall, 859 care recipients have been recruited for the Carewell project. Of these, 477 have been assigned to the intervention group. Patients were equally distributed regarding gender (50.5% of men), with a mean age of 77.6, 95% CI (77.1, 78.1). The most frequent disease in the project population was DM (66.4%) followed by CHF (61.8%) and COPD (54.1%). The care recipients have a high degree of independence with a Barthel index median of 100, IQR (80,100). Conclusions : Evaluation of integrated healthcare service delivery processes will improve the current scientifically based knowledge on barriers and facilitators towards integrated healthcare delivery.

Introduction : The benefits of having a healthy lifestyle are widely known, a healthy diet and being physically active are key elements in improving and maintaining optimal health. However, studies on dietary habits in adolescents suggest that the adherence to the Mediterranean diet is being reduced, decreasing the consumption of vegetables and fruits. Also, according to recent studies the Spanish teenager population practices less physical exercise comparing with the Europe teenager population. All this is causing an increase in sedentary lifestyles, a decrease in energy expenditure and an increase in obesity. Short description : An intervention program to promote healthy lifestyle has been designed and implemented. The program is aimed at students (12-14 years old) of 2 schools in Irun (Basque Country). The intervention will consist of the "Bidasoatik Mundura, Sasoi Erronka" program that encourages students to join the challenge of going around the world through an imaginary tour and performing activities of different countries. The study is a quasi-experimental pre-post study with a control group (2 different schools) and an intervention group. The program addresses three aspects: physical activity by participating in activities designed and related to different countries; healthy eating with educational training by experts and creativity by developing a video summary of what happened in the quarter. Also, students will receive two educational workshops given by two nutritionists whose content will focus on the importance of healthy lifestyles. For the development of the program the website www.bidasoatikmundura.eus has been launched. It is an interactive, intuitive, attractive and updated website that will serve as a reference for the different activities that are being performance in schools tool. In the webpage, the students will learn about the activity they need to develop, meet weekly scores and standings, can find information about healthy habits and can answer to questionnaires on diet and they can view videos developed by each school. Results : The expected result is an increase in the level of physical activity and increased adherence to healthy eating habits of 362 adolescents aged 12-14 years old. For this, the level of physical activity, sedentary time and dietary habits at the beginning and end of the intervention will be evaluated through validated questionnaires (ASAQ, PAQ-A, KIDMED) and compared with data collected in the control group. Highlights : The key elements for the success implementation of the program identified to date are: - Design of a program of health promotion and promotion of lifestyles schools. The design has to be a collaborative work with the intervention of different stakeholders: teachers, health professional, public health professionals, researchers… - Involvement of teachers for the implementation and deployment of the program is essential for the success of the program. - The importance of use of new technologies (webpage) for the management and monitoring the program and the interaction among adolescents. Conclusion : The school is an ideal place to promote healthy lifestyles, and all adolescents (12-14 years old) are in compulsory education and it is the age in which the personality develops ,making it easier to acquire habits of place life.

Purpose: To assess the perception of health care professionals of the organisational prerequisites for implementation of telehealth interventions in search of a generally applicable model for future use of telehealth. Context: United4Health, a European telehealth project comprising three multicentre studies of telehealth services for patients with diabetes, COPD and chronic heart failure in 10 European countries. Methods: Based on the Model for ASsessment of Telemedicine applications (MAST) [1] , data from three multicentre observational studies of telemedicine services for patients with diabetes, COPD and chronic heart failure were analysed to assess organisational impact. Data collection was based on a shared protocol developed by the U4H evaluation team. Data were collected by means of interviews with key members of the local health care professional teams and in addition studying policy documents and descriptions of clinical pathways. Analysis of the interviews was performed by means of identifying recurring themes and subsequently using content analysis. Results: From the assessment we were able to point out a number of key prerequisites which were needed in order to successfully implement the telehealth solutions and achieve their integration in routine health care services in care of patients with selected chronic diseases. Among the key factors for successful implementation are: National focus on telehealth Very careful consideration of choice of patient groups (inclusion and exclusion criteria) Realistic expectations for time and staff resources required IT infrastructure in place and running smoothly from the beginning Adequate training for staff and patients involved in the trial Discussion: Due to differences in organisational set-ups, as well as actions taken outside the project such as national health reforms and new health care policies, we were not able to point out a single model which would be suitable for all. Even though a common clinical protocol was produced including description of the content and duration of the telemedicine service, the interventions were quite similar among the sites, but the organisational set up differed widely. Keywords: Telehealth, integrated care, organisational changes, Diabetes, COPD, CHF References: 1. Kidholm K et al. A model for assessment of telemedicine applications: MAST. Int J Technol Assess Health Care. 2012 Jan;28(1):44–51

Proteolytic signalling cascades control a wide range of physiological responses. In order to respond rapidly, protease activity must be maintained at a basal level: the component zymogens must be sequentially activated and actively degraded. At the same time, signalling cascades must respond precisely: high target specificity is required. The insects have a wide range of trapping- and tight-binding protease inhibitors, which can regulate the activity of individual proteases. In addition, the interactions between component proteases of a signalling cascade can be modified by serine protease homologues. The suicide-inhibition mechanism of serpin family inhibitors gives rapid turnover of both protease and inhibitor, but target specificity is inherently broad. Similarly, the TEP/macroglobulins have extremely broad target specificity, which suits them for roles as hormone transport proteins and sensors of pathogenic virulence factors. The tight-binding inhibitors, on the other hand, have a lock-and-key mechanism capable of high target specificity. In addition, proteins containing multiple tight-binding inhibitory domains may act as scaffolds for the assembly of signalling complexes. Proteolytic cascades regulated by combinations of different types of inhibitor could combine the rapidity of suicide-inhibitors with the specificity lock-and-key inhibitors. This would allow precise control of physiological responses and may turn out to be a general rule.

Aging, a time-dependent functional decline of biological processes, is the primary risk factor in developing diseases such as cancer, cardiovascular or degenerative diseases. There is a real need to understand the human aging process in order to increase the length of disease-free life, also known as “health span”. Accumulation of progerin and prelamin A are the hallmark of a group of premature aging diseases but have also been found during normal cellular aging strongly suggesting similar mechanisms between healthy aging and LMNA-linked progeroid syndromes. How this toxic accumulation contributes to aging (physiological or pathological) remains unclear. Since affected tissues in age-associated disorders and in pathological aging are mainly of mesenchymal origin we propose a model of human aging based on mesenchymal stem cells (hMSCs) which accumulate prelamin A. We demonstrate that prelamin A-accumulating hMSCs have a premature aging phenotype which affects their functional competence in vivo. The combination of prelamin A accumulation and stress conditions enhance the aging phenotype by dysregulating the activity of the octamer binding protein Oct-1This experimental model has been fundamental to identify a new role for Oct-1 in hMSCs aging.