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Key conclusions:

(1) In order to kick off integrated care reform in a

locality it is necessary to provide awareness raising to all parties

involved and the population as well as the means that will cover the

reform cost and assure sustainability of operations in the long run.

(2) For that it is necessary to run a social enterprise in a PPP form, to

manage the Territorial Care Hub that will centralize organization,

coordination, management and delivery of all Long TermCare services.

(3) This structure should not depend on neither health nor social

policy central authorities for better response and efficiency and should

be run locally by a new institution built to cover health, prevention

and care for at least the primary and long term care services of

the population. If secondary healthcare can also be aligned with

hospitals and clinics this would be better, but it concerns usually

advanced integrated care systems, aligned care costs reimbursement

and abundance of state resources and investments, 4) Investment,

innovative financing and business innovation is necessary for any

community care structure that wants to run sustainable care opera-

tions in the long run without crises, (5) the first priorities to imple-

ment integrated long term care by order of priority are: a. leadership

awareness and on-the-job training b. Deliberation of the integrated

LT care plan with all the local health ecosystem stakeholders, not only

those concerned by health sector. The vision, strategy and action plan

have to be endorsed by the entire ecosystem c. build the right

investment blend until the Care Hub is sustainably run with constant

RoI d. the Care Hub management has to be not for profit, independent

from central authorities and abide to local control for commissioning

services e. Workforce training in additional to care skills and patient

empowerment are key for the success of this model.


Efficacy of a nursing home GP service in London

K. Tully.

Sternhall Lane Surgery

For the past 2 years a team of GPs in South East London have been

providing a dedicated primary care service to local nursing homes. The

services involves regular geriatrician and multidisciplinary team input

and much work on advance care planning. To measure our impact one

of the factors we looked at was the rates of avoidable emergency

admissions to hospitals and

Accident & Emergency

attendances. We

compared the rates from 2013/2014 (before the service was commis-

sioned) with the rates in 2014/2015 and found a reduction of 23% and

24% respectively. We conclude from these figures that this is a cost

effective model of providing good quality care for the elderly in the

community. (Poster presentation would include graphs and elaborate

on the details of the service)


Adult ventilator weaning program in tertiary care center Qatar

S. Acharath valappil, H. Al hamad, E. Al sulaiti, A. Darwish,

N. Nadukkandiyil, M. Refae, F. Umminiyattle, M. Al husami, O. Idris,

J. Liza, G. Fawzy, G. Al tamimi, Z. Ben hassine, G. Khouri.

Hamad Medical

Corporation, Doha, Qatar


It was realized that many ICUs and acute beds in Hamad

Medical Corporation hospitals in Qatar were occupied by Long term


ventilated patients who were otherwise medically

stable. These patients were previously scattered in different units that

made the task of providing optimal care very difficult. Once these

patients are transferred to Rumailah hospital adult ventilator unit, it

became apparent that there was an ideal opportunity to wean some of

these patients off the ventilators thus improving their prognosis.


Aim is to cohort the chronic ventilated patients to single

specialized unit for early weaning process. An Adult ventilator wean-

ing team was formed comprising of physician, nurse and respiratory

therapist. After initial assessment in acute care hospital, patients were

admitted to adult ventilator unit. Patient is assessed by the weaning

team, starts weaning trial if patient is fit for weaning. This is followed

by family conference and multi-disciplinary team conference leading

to successful discharge or transfer to the wards.


Total 104 cases were disposed till March 2016, among these

40 cases identified as weanable from ventilator, and 24 cases were

successfully weaned and discharged or transferred.


The program has implemented the best of evidence

based medicine and created customized care plans for each patient

that has led to the significant improvements. The program has

achieved success in weaning, one patient/month with active rehabili-

tation with an annual Cost savings: $ 2500 per year /patient.


The IBenC Project

benchmarking costs and quality of European

community care

H.G. van der Roest


, A. Declercq


, V. Garms-Homolová


, G. Onder



H. Finne-Soveri


, P.V. Jónsson


, J.H. Smit


, J.E. Bosmans


, H.P.J. van





VU University medical center, Amsterdam, The Netherlands;


University of Leuven, Leuven, Belgium;


Hochschule für Technik und

Wirtschaft Berlin, Berlin, Germany;


Università Cattolica Sacro Cuore,

Rome, Italy;


National Institute for Health and Welfare, Helsinki, Finland;


University of Iceland, Reykjavik, Iceland;


GGZInGeest, Amsterdam,

The Netherlands;


VU University Amsterdam, Amsterdam, The



High quality community care may prove to be a cost

effective solution for the future in comparison with institutio-

nalization. Insight into which type of community care delivery

provides the best outcomes against reasonable costs is lacking. The

IBenC (Identifying best practices for care-dependent elderly by

Benchmarking Costs and outcomes of community care) project is a

cross-European study with the aim to identify best practices in

community care for care-dependent elderly people, by benchmarking

the cost-effectiveness of community care delivery systems in Europe.

A new benchmarking method will be developed, based on a

standardized comprehensive geriatric assessment instrument, the

Resident Assessment Instrument for Home Care (interRAI-HC).


The study has a prospective longitudinal design. Data

collection took place amongst community care recipients of 65 years

and older in Belgium, Finland, Germany, Iceland, Italy, and the

Netherlands. To enable an in-depth interpretation of best performing

practices, the contexts and characteristics of community care

organizations and community care staff are studied cross-sectional.


At baseline 38 community care organizations, 2884 commu-

nity care clients, and 1086 community care professionals were

included in the study. First results on the study population and the

benchmarking method will be presented.

Key conclusions:

The project will provide health care policy makers

comprehensive insight into the functioning of the European commu-

nity care systemby taking into account patient outcomes, costs of care,

organizational performances, and into the role that structure and care

processes of care organizations plays in care performance.


Healthy active ageing supported by technological environment:

the DOREMI experience

F. Vozzi


, L. Fortunati


, C. Gallicchio


, F. Palumbo


, A. Micheli



S. Chessa


, E. Ferro


, O. Parodi




Institute of Clinical Physiology, IFC-CNR,


Institute of Science and Information Technology, ISTI-CNR,



of Computer Science, University of Pisa, Pisa, Italy


European population aging requires the design of

innovative solutions able to support, in term of quality and time, its

health status. DOREMI project has developed an innovative platform

able to stimulate and monitor elder people as also to be customized on

user requirements.


34 older people (age 65

80 years) were involved in UK

and Italy DOREMI trials (3 months). Subjects were characterized at

baseline in terms of physical activity (SPPB, PASE test, daily steps/

meters, 6MWT), hemodynamic and biochemical parameters (blood

pressure, HR, lipid profile, glycaemia, etc.), dietary habits (caloric

intake) and balance assessment (BERG scale). Through the DOREMI

Poster presentations / European Geriatric Medicine 7S1 (2016) S29