ACT Programme


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ACT Programme

The Advancing Care Coordination & Telehealth Deployment (ACT) Programme brings together a pan-European consortium of leading companies, universities, hospitals and healthcare authorities. Initiated in February 2013, the 2.5-year programme will define best practices in care coordination and telehealth. The objective of this EU co-funded project is to overcome the structural and organizational barriers of the deployment of coordinated care. The ACT programme addresses a primary challenge facing healthcare systems in EU member states: the ageing population and the related burden of chronic disease. By specifically investigating four key drivers, influencing the effective deployment of Coordinated Care & TeleHealth services and generating 'best practice' examples, ACT provides the foundation to help overcome organisational and structural issues in patient stratification, patient and staff engagement, optimisation of organisational structures, and efficacy and efficiency.

The potential of Coordinated Care & Telehealth services, not only to reduce the economic burden of chronic care, but also to improve the delivery of clinical support is endorsed by scientific evidence gathered mainly in clinical trials. However, such services have not yet progressed substantially beyond pilots and test installations. Translating the evidence to large scale deployment requires a change in the behaviours, routines and cultures. The ACT programme is conceived to address this challenge together with the key stakeholders; leading industries, universities, hospitals and healthcare authorities and also five European Healthcare regions are taking part: the Basque Country (Spain), Catalonia (Spain), Scotland (UK), Groningen (Netherlands) and Lombardy (Italy).

The ACT Programme explored the organisational and structural processes needed to successfully implement care coordination and telehealth (CC&TH) services on a large scale. By monitoring CC&TH initiatives in the five European regions described below, the ACT programme has created a ‘cookbook’ of good practices to facilitate CC&TH deployment on a large scale. This could potentially transform care for millions of chronically ill people, and save healthcare systems billions of Euros each year.


Five European regions have committed to deploy and operate their preferred care coordination and telehealth solutions, sharing experiences and data: Scotland, Northern Netherlands, Lombardy, Catalonia and Basque Country. Starting in February 2013, an initial six-month study will determine a baseline of how Care Coordination and Telehealth is deployed in the regions. After the initial study, the care structures and procedures will then be optimized and evaluated during an 18-month period. As the services are being evaluated within existing healthcare eco-systems, supporting large cohorts of patients, best practice results will be verified with the necessary 'real world' rigour, ensuring the findings can be replicated in other EU health regions, taking into account the regional/national boundary conditions & other diversity aspects. Best practices will be compiled into a 'cookbook' for large-scale telehealth deployment via disseminations activities by the ACT programme.

Region Descriptions

  1. Basque Country
  2. Catalonia
  3. Lombardy
  4. Scotland
  5. Northern Netherlands


The table below provides an overview of all the regional that participated in the ACT programme. The table provides each region’s programme acronym, full programme name, and the elements of each of their programmes. For instance, does it support telehealth (TH)? Or does it have elements to support multi-morbidities (MM)? Finally, the programmes are classified into clusters of similar types.

Programme Elements

The programme supports multi-morbidity.
The programme includes telehealth.

Programme Clusters

These are the prevention, educational, active patient programmes.
These are the transitional care and post discharge programmes.
These are chronic disease or multi-morbid management long term programmes, excluding telehealth elements.
Chronic TH
These are chronic disease or multi-morbid management long term programmes, including telehealth elements.
These are elderly at home programmes.

ACT Programmes

Overview of all ACT programmes, their elements and cluster classification.

Data collection

The duration of the project was 32 months, starting in February 2013. Baseline data was collected in month six to report how CC&TH pathways are integrated and accepted in the regions. The table below summarises the data collection: The baseline describes data collected from programme managers, frontline staff, patient adherence, and staff engagement. It also provides an overview of the status quo of the region at the start of the project. Iteration data was collected in months 14, 18 and 26, respectively. During the iteration phase, specific data was collected and evaluated for the years 2012, 2013 and 2014.

Data availability & responses

Data collection overview

Overview of the iterations for the data collection and the data collected.

Consort diagram for baseline and indicator data

Consort diagram for baseline data on care coordination and workflow structures, staff engagement and indicator data.

Consort diagram for follow-up surveys

Consort diagram for follow-up surveys for the programme manager, frontline staff and patients.

Evaluation Engine

The ACT evaluation engine is responsible for capturing, monitoring and evaluating CC&TH deployment, using collected data. This web platform is able to publish, manage, and analyse on-line surveys, collect quantitative indicators via on-line of off-line templates, visualise stored information in multiple views and export data for further statistical analysis. The data is organised as key drivers (generic aspects of healthcare programmes determining their quality with respect to CC&TH) and key indicators (measurable healthcare outcomes used for assessing the drivers). These drivers and outcomes are important considerations when deploying CC&TH at scale. Figure 3 presents an overview of the evaluation engine. The engine has been built on open source technology to offer a content management system with a database. It offers surveys, statistical analysis and interactive visualisations. The analysis performed by the domain experts has been added in the evaluation engine, and run on the collected data.

The engine supports:

  • A central point of authorised data entry and navigation in the system.
  • An online survey tool, with questionnaires for different users, regions, and groups of indicators.
  • Import modules for survey data from the survey tool, and external sources.
  • Import module for quantitative data templates.
  • A data model, which supports integration of data originating from different sources into a common database.
  • Raw data and descriptive visualisations of programme details, stakeholder perceptions, and comparison to a reference.
  • Full interactive implementation of the evaluation framework, which that can be used for hypothesis generation of good practices