United4Health – information in English

Sorlandet Hospital HF, University of Agder, Tromso Telemedicine Centre and University Hospital Nord-Norge are participating in the 3-year EU-project United4Health, starting up in January 2013. In this project more than 20 countries are involved in clinical trials which include more than 20.000 patients with chronic diseases, where 85 patients will be included in the Agder region. The study involves the municipalities of Agder, with the municipality of Kristiansand as a pilot for testing out the telemonitoring program.

The study aims to demonstrate that:

Clinical outcomes

The introduction of a short-term intensive telemonitoring programme (TMon) followed by a less intensive ‘step down’ TMon for COPD patients discharged from the hospital after an exacerbation, reduces hospital re-admissions from COPD exacerbations over the following year

Organisational outcomes

The required organisational changes can be implemented at scale in a timely way. The TMon will result in a work load for the staff that is acceptable.

The required organisational changes and new ways of working are agreed and approved by the appropriate management structures within the relevant local agencies involved in the delivery.

The intervention models can be successfully transferred to other regions and mainstreamed as part of usual care.

Economic outcomes

The TMon for COPD care pathway is more cost-effective compared to usual care.

Other outcomes

The new service is acceptable to all stakeholders including patients and health professionals.

More information on the EU-study: www.united4health.eu.

Chronically ill patients needs close follow-up at Point-of-care as home treatment, where different health care organizations needs to have close collaboration. In several projects, the hospital will follow up patients for a period of time after hospital treatment, in order to avoid re-admission to the hospital. Based on the “Collaboration reform” in Norway, this remote home monitoring information should be available both at the hospital, at the local doctor’s office and at the municipality health care services/home nurse, in order to establish a coordinated team for home treatment. This will require new technological solutions with shared access to medical information, and new procedures for patient flow and long-term treatment in a close team-work involving the actual competence needed.

The VERDIKT- project is a follow-up and spin-off from the European project United4Health. We have identified major obstacles for transition from a trial project into permanent new ways of patient care and follow-up, and we will focus on developing technical solutions and guidelines for implementation of future health care services taken into account actual measures to meet those obstacles:

  1. Organizational innovative changes based on the patients daily follow-up at point-of-care, according to the Norwegian “Collaboration reform”.
  2. Juridical regulations in collaboration of patient treatment and care, with implementation of secured access to shared information recorded and stored within the Norwegian Health Network
  3. Integration into existing health care data services.
  4. Patients access to medical information and treatment plans.
  5. Standardizations in technological solutions.

Contact information technical solutions and research/evaluation:
Rune Fensli, University of Agder