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SIMPHS3 - Integrated care services

The Strategic Intelligence Monitor on Personal Health Systems Phase 3 (SIMPHS3, 2014-2015), third and final phase of the SIMPHS project, looked at integrated care services – including telehealth, telecare and independent living solutions – for older patients with chronic conditions.

The aim was to define operational guidelines for further implementation in European regions. It focused particularly on drivers and barriers, and on business and organisational models for integrated care services and independent living solutions. Ultimately, the research helped us assess the role of ICT in facilitating the integration of healthcare and social care.

The SIMPHS3 outcomes contributed to the goals of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) by providing guidance for stakeholders involved in scaling up good practices.

The focus of SIMPHS3 related to the activities undertaken in the EIP on AHA Action Group B3 (replicating and tutoring integrated care for chronic diseases, including remote monitoring at regional level) and those of Action Group C2 (development of interoperable independent living solutions, including guidelines for business models).

The research started with the definition of a methodological framework which devised an approach for the selection and development of case studies on ICT-enabled integrated care services, and developed a framework of analysis.

A literature review was organised in three steps in order to 1) identify from the scientific literature an agreed definition of integrated care, 2) select potential best cases among the EIP on AHA reference sites and 3) identify potential success cases from other sources (scientific literature, grey literature and EU-funded project information).

As a result, 24 cases were identified for further study. The analysis of these 24 cases which is provided in 24 separate case reports served as a basis to discuss models of organisations and develop guidelines for further implementation of integrated care and independent living in European regions.

Brief description of the published case studies and a link to each case report:



Borås municipality, Western Sweden (Sweden)

Self-care and family care support service provided through ICT installed at patients’ homes


Emilia-Romagna (Italy)

Implementation of integrated home care services for COPD patients.


Skåne Region (Sweden)

Improving cooperation between home care, elderly home care, primary care and hospital care to better coordinate care of the elderly


Badalona, Catalonia (Spain)

Integrated care organisation offering health and social care services.


Cork and Kerry South-West Region (Ireland)

Screening, triage, assessment and treatment to reduce risk of frailty and adverse outcomes in community dwelling older adults


Breitenstein, Lower Austria (Austria)

Remote monitoring of diabetes patients using mHealth


Barbastro, Aragon (Spain)

Remote monitoring services to help the elderly live independently


Trikala municipality, Thessaly Region (Greece)

Telehealth/telecare services for chronic patients and the elderly and social services to all citizens.


Basque Country (Spain)

Integrated person-centred care model for the elderly


Kinzigtal region, Baden-

Integrated care and preventive services offered to the population covered by the health insurances


Württemberg (Germany)

AOK and LKK, based on a shared savings contract between Gesundes Kinzigtal and AOK/LKK.

Int. Care Getafe

Getafe, Madrid (Spain)

Integrated care programme for older in- and out-patients

Healthcare PPI

Galicia (Spain)

Public Procurement of Innovation projects and experiences developed in the healthcare system of Galicia


Twente (Netherlands)

Helping the elderly to live independently for longer periods in their own environment.


Languedoc-Roussillon (France)

Innovative solutions through living labs to improve care for chronic patients



Care model based on a multi-disciplinary 24/7 advanced technology call centre for treatment of various chronic diseases (including remote monitoring)


Barcelona, Catalonia (Spain)

Integrated care services for chronic patients based on structured interventions addressing prevention, healthcare and social support.


Oulu (Finland)

Cloud services that can support integrated care services and allow the elderly to monitor their own well-being and manage their own health.


Brescia/Lombardy (Italy)

Anticipatory care planning to manage patients with chronic diseases (e.g. Dementia, Alzheimer)

Renewing Health

Carinthia (Austria)

Pilots to integrate telemonitoring solutions with existing systems for diabetes type 2 and COPD patients and assess impact of the system


Region South Denmark (Denmark)

Encouraging local health and social care actors to launch integrated health care initiatives through shared agreement protocols of collaboration.


Emilia-Romagna (Italy)

Interoperable infrastructure enabling the development of integrated care services for the whole population of the region.


Scotland (United Kingdom)

Local integrated care initiative which uses a population pre-screening model to measure patients’ risk of emergency admission in hospitals in order to deliver anticipatory care planning..


Scotland (United Kingdom)

Funding and stimulating the implementation of telecare projects in the local community by health partnerships throughout Scotland.



Integrated care model for elderly veterans and their caregivers