BMJ publication


The work performed by Prof. Roca in Collaboration with Kronikgune and the rest of the ACT consortium on risk stratification has been accepted for publication on BMJ Open. Click here to download the full article.

Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme ( The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario.

Press Release Spain

In collaboration with AQUAS and the hospital clinic, Philips has presented the ACT cookbook to the media on the 17th December in Barcelona. The book provides special emphasis on the Catalan programs that are identified as good practices of coordinated care and telehealth.

Press release (Spanish)


Cookbook for large scale coordinated care and telehealth deployment debuted by Philips-led European consortium of leading companies, universities, hospitals and healthcare authorities

Amsterdam, Netherlands– Royal Philips (NYSE: PHG, AEX: PHIA) and its ACT-program consortium partners today announced the debut of a cookbook outlining key enablers necessary to scale connected care and telehealth programs. The cookbook is the result from a two-and-a-half year scientific evaluation of data from different connected health programs in five European regions. It provides new insights that apply across the EU on why certain telehealth programs are more successful than others.

IFIC Integrated Care Webinar 1 - Understanding Integrated Care

This presentation is part of the International Foundation for Integrated Care's Webinar Series organized in association with Edgehill University. Over the past decade many definitions, concepts and theories have emerged trying to explain what integrated care is and what the main building blocks for successful integration of services across sectors and professions may be. In this first webinar Dr Nick Goodwin gives a comprehensive overview of the most influential concepts, analyses the lessons learned so far and highlights the complexities of designing such systems on local, regional and national level. In doing so he also highlights the pitfalls which many integrated care initiatives encounter and illustrates with practical examples how integration of health and social services make it work.

Presenter: Dr Nick Goodwin, CEO, International Foundation for Integrated Care


Building blocks of integrated care webinar series

The International Foundation for Integrated Care in association with Edgehill University are delighted to present this series of webinars “The Building Blocks of Integrated Care”. Six webinars will run on a monthly basis from October – March, in the lead up a public lecture on 14 April 2016 at Edgehill University by Professor Jon Glasby entitled If integration is the answer, what was the question? What next for health and social care partnerships. The webinars are targeted at all those interested in improving their core knowledge of integrated care principles and techniques. Webinars will draw on academic research and practical examples.

This webinar series will give a comprehensive overview of the different building blocks of integrated care, illustrating concepts with numerous practical examples from around the world. By mixing presentations with live question and answer sessions, participants will also have the chance to ask burning questions in a relaxed and safe environment. Background material and recommended reading lists will also be available for download.


Thursday, 22 October 2015 3pm – 4.30pm CET (2pm – 3.30pm GMT)


Wednesday, 11 November 2015 3pm – 4.30pm CET (2pm – 3.30pm GMT)


Wednesday, 9 December 2015 – 4.30pm CET (2pm – 3.30pm GMT)


Wednesday, 27 January 2016 – 4.30pm CET (2pm – 3.30pm GMT)


Wednesday, 24 February 2016 – 4.30pm CET (2pm – 3.30pm GMT)


Wednesday, 23 March 2016 – 4.30pm CET (2pm – 3.30pm GMT)

Publication of the ACT Cookbook

We are very excited to announce that the ACT 'Cookbook' has been published on Wednesday October 15, 2015.

After monitoring care coordination and telehealth initiatives in five EU healthcare regions – Lombardy (IT), Basque Country (ES), Catalonia (ES), Northern Netherlands (NL), and Scotland (UK) – the ACT programme has produced this ‘cookbook’ for large-scale deployment of coordinated care and telehealth. This ‘cookbook’ of good practices identifies best-in-class processes, structures and ways of working from these five partner European regions. Their insights, conclusions and recommendations, presented here, can be used to build a blueprint for large-scale care coordination and telehealth deployment across Europe.

ACT Cookbook to be launched at the largest public health event in Europe.

8th European Public Health Conference (EPH)

Health in Europe – from global to local policies, methods and practices
14 - 17 October 2015
MiCo, Milan, Italy 


The largest public health event in Europe, the 8th European Public Health Conference is held in conjunction with the 48th National Congress of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI).

The EPH Conference helps improve public health in Europe by proving a platform for exchanging information. Contributors include researchers, policy makers, practitioners in the field of public health, health services research, as well as public health training and education in Europe.

Integrated care is considered the way forward in helping to overcome the demands of our ageing population, and its explosion in chronic health.

The Advancing Care Coordination & Telehealth Deployment (ACT) Programme is the first to explore the organisational and structural processes needed to successfully implement CC&TH services on a large scale.

Highlighting the good practices around the deployment of CC&TH, the new ACT Cookbook will be launched at the conference by Cristina Bescos, ACT programme manager.  

The ACT Cookbook launch will take place between 11.00 - 12.30 on Wednesday 14 Oct during Session B: Opportunities behind the crisis: from a purely budget constraint approach to better outcomes and performance. 

Invited panellist Cristina Bescos will discuss the ‘opportunity behind the crisis’ together with Maria Antonia Iglesias, EC Head of Unit DG Sante, and representatives from the Ministries of Health of Italy and Poland.

EIP on AHA B3 Action Group Webinar on Change Management in Integrated Care

EIP on AHA B3 Action Group on Integrated Care invite participants to the first B3 Webinar on ‘Good practice on change management: Maccabi Multidisciplinary Telemedicine Centre for Chronic Disease Management’, which will take place on Thursday 6th August, 14.00 CEST.

The aim of this webinar is to present interactively the experience of Israel in the deployment of a 24/7 call centre of highly trained nurses supported by other professionals providing proactive care to patients with chronic diseases using computerized clinical care pathways and videoconferencing. The example will serve to present the work of the B3 AA2 Group on Change Management and the B3 maturity model in a concrete practice.

The host and presenters are:

  • Stella Tsartsara, B3 Promoter (webinar host)
  • Cristina Bescos, Philips Healthcare (Co-ordinator of the B3 Action Area 2 Change Management group)
  • Angela Irony, Director of Maccabi On Line Medical Centers
  • Avital Segal, Deputy Director, Medical Online Medical Services MOMA (Multidisciplinary Telemedicine Center for Chronic Disease Management)
  • Rachelle Kaye, Strategic and International Consultant, Maccabi Healthcare Services (B3 Action Group member)

If you wish to participate, please register via this link – – and you will receive an email with joining instructions.

Please feel free to disseminate this information across your network.

You can find a full outline of the session here:B3 AA2 Webinar – Session Outline

ACT presentation at the IUMP in Santander

On the 3rd July, in the picturesque city of Santander, in the north of Spain, Cristina Bescos, from Philips, presented an overview of the ACT program to the students of the summer course on telemedicine of the International University Menendez Pelayo: IX ENCUENTRO E-SALUD Y TELEMEDICINA. TIC PARA LOS RETOS DE I+I EN SERVICIOS DE SALUD EN ENFERMEDADES CRÓNICAS .

The event is targeted to a wide spectrum of professionals including innovators, researchers and interested professionals in health services and ICT services for health, and in general to all those who are interested in debating around the state of the art and tendencies of the R&D in health and are services of chronic diseases.

The three day course held in Spanish, presented some technical innovations to the health research community: Big Data, Open Data, Cloud e Internet of things. On the third day, together with ACT, the RAHEE related to cost/effective evaluation for interventions on chronic disease management and the joint action CHRODIS-JA were presented.

ACT project goes beyond the trial setting to assess programme deployment in five EU regions (Lombardy, Basque Country, Catalonia, Groningen and Scotland). Fully aligned with the European Innovation Partnership on Active and Healthy Aging (EIP on AHA- B3 group on Integrated Care) objectives, it aims at identifying best practice organisational and structural processes supporting integration and implementation of telehealth in a care coordination context for routine management of patients with long-term medical conditions. ACT methodology is based on a new framework of key performance indicators for CC&TH outcomes and drivers that define data elements collected during the project, combining quantitative and subjective methods, process and outcome indicators. An evaluation engine is responsible for capturing, monitoring and evaluating CC&TH deployment, using iterative collected data. The areas that are addressed in the ACT program are patient & population stratification, care coordination and organisation, patient adherence & staff engagement, and efficacy & efficiency.

ACT 6th General Assembly in Barcelona

The ACT consortium held its last General Assembly on the 17th and 18th June in Barcelona, kindly hosted by the Hospital Clinic and IDIBAPS. The successful meeting gathered more than thirty experts from the ACT regions, scientific community and industry.


The aim of the meeting was to explain and discuss the final work on the holistic evaluation, including risk stratification, staff and patient engagement, patient focus groups, organization optimization and outcome analysis for the different programs assessed. WP3 also presented the final progress of the ACT evaluation engine with the holistic dash-boarding capabilities, surveys, and data collection and analysis of drivers and outcomes.

On the second day we concentrated the discussions in the morning around the ACT cookbook: criteria selection and presentation for the ACT best practices and the ACT cookbook final document and dissemination strategy in September-October.

In this occasion we had the pleasure to invite various program managers from Catalonia and Groningen to discuss about their progress and their experience at the ACT project: The Chronic Care Model in BSA was detailed by Jordi Piera, The Complex Chronic Patient Programme in Alt Penedès by José Carlos Molina – Hospital Comarcal Alt Penedès and the Integrated Care programme in Osona by Joan Espaulella – Hospital Vic. Furthermore, Joan Escarrabill presented the AISBE programmes analysed by ACT . From Groningen, Esther Metting presented a new clustering approach for optimizing the treatment of Asthma COPD patients and Coen Ronde provided an overview of the EMBRACE programme .

Parallel to the ACT session, the hospital Clinic in collaboration with AQuAS (Agency for Quality in Health) organized a session to promote the plans for integrated care, telemedicine in Catalonia for 2016-2020: Mr. Josep M. Argimon, AQuAS director presented the deployment strategies for the period. Josep Samitier, IBEC director, discussed aboutthe role of EIT-Health as accelerator of the deployment, while Josep M. Piqué, Hospital Clínic general director, guided us though the past and future commitment of Barcelona-Esquerra. The session was chaired by Christoph Westerteicher, Hospital to Home business Manager at Philips.

In summary, we completed successfully another key milestone of the programme: all ACT deliverables have been submitted and approved on time, we have an agreed conception and communication plan for the ACT Cookbook. We are further looking into extending this fruitful collaboration in the future.