Recommendations for staff engagement, patient adherence, stratification and assessment.

Staff Engagement

  1. Clarity on program aims and benefits

    Programme managers should provide staff with clarity on aims and patient benefits l

    Findings from ACT suggest that no single intervention can ensure staff engagement. Yet it is clear that frontline staff should give a clear insight into the potential benefits of the programme.

    When frontline staff see patient benefits, and believe in the benefits of the programme, these are powerful drivers of engagement. It helps staff to engage with programmes, and take on extra workload. Programme managers should be aware of this. Taking the opportunity to publicise and celebrate the successes and benefits of the programme. Frontline staff are often the first to recognise the positive impact on patients. Their experiences should be sought out and shared with the communication and feedback channels discussed earlier.

    Qualitative data from frontline staff provides useful insights and benefits, which could be used to support implementation:

    " Patient care is more personalised and integrated across the organisation (coordination between different services). The aim is to adjust the services to the needs.”

  2. Participation in program development

    Programme development that is early, ongoing, and responsive

    Communication is an important element of any staff engagement strategy. It is important that it is not one way, infrequent or just a token effort. Programme managers should seek to interact on a regular and inclusive basis. Acting upon any staff feedback wherever possible.

    The ACT programme suggests that early staff involvement helps raise awareness of programme aims. It also enables the development of clinical champions, and identifies early barriers to change.

    The results of the ACT project also pinpoint that consultation should be ongoing. This allows for progress updates and effective partnership working on emerging issues. It is crucial that staff are not ‘spoken to’ by programme leads. They should feel that their feedback can further shape the development of the service.

    Qualitative feedback provides insights into programme development. It suggests the importance of giving staff a voice. Together with recognition of the need for staff input from programme managers.

    "I think the organisation, and its managers, should approach this issue in a planned way. Carrying out a dialogue with the clinicians.”

  3. Regular interactions

    Elevate levels of staff engagement on regular occasions

    Levels of staff engagement within ACT programmes have been studied closely. It results in a new level of scrutiny and evaluation. Which should not be restricted only to primary research. It should also be an element of all staff engagement strategies.

    There is a comprehensive survey tool developed for the ACT programme, combining scores and textual information from stakeholders. It tracks and gathers views of frontline staff on engagement activities and progress. It also shows the importance of staff engagement within a project plan. Programme managers should make regular use of this tool. It can also help them bring staff on board with programme development and delivery.

    The justification for this recommendation lies in the outcome of the ACT programme. The views gathered from staff have been exceptionally useful. It has outlined the most important elements of their engagement with the programme. Views that help guide how these need to be implemented as part of a holistic package. Recognising those areas that need most work, it has also helped to identify best practice.

    Using a staff engagement evaluation tool is a useful process. It should part of any future programme development.

  4. Maximise engagement

    Maximise engagement among the workforce with staff training, tailored to different grades and groups

    Certain measures are needed to ensure staff engagement and acceptance of organisational change. These include tailored staff training and monitoring of staff satisfaction.

    Before training staff, establish a demand for the service. This will ensure the existence of a coherent framework in which to train staff. Carrying out successful coordinated care depends on a well-trained workforce. It also depends on meeting their diverse development needs. Consultation and support are needed for the day-to-day staff, who run the service.

    The analysis shows that tailored staff training and a well-informed workforce are necessary. These will achieve a collective sense of positive purpose among staff. As well as a shared understanding of the future plans of the organisation. Managers should allocate time for the staff training and recognise its importance.

  5. Continuous feedback

    Continuous feedback between professionals, service operators and project teams is vital

    Continuous feedback ensures that evolving needs are met and change is made step by step. Examples of poor communication were reported between different services. This led to tensions between healthcare professionals. Some were reluctant to get involved. While others had become isolated due to lack of support. A number of programmes made steps to address this problem:

    "A conscious strategy to elicit feedback helps to address obstacles. It provides a good service, with a high turnover of both staff and patients"

Patient Adherence

  1. Personalized strategies

    The need for personalised strategies to overcome adherence barriers

    Healthcare systems, programmes, personalities, and – importantly – patient profiles vary substantially. For this reason, we need to design adherence strategies that are adapted around the needs of the patient. Not only clinical, but also social and socioeconomic needs.

  2. Routine iterative evaluations

    Routine iterative evaluation of patient adherence should be implemented in healthcare programmes. This will help foster coordinated care and telehealth

    One single standardised procedure cannot assess the level and quality of adherence. Or the factors that limit it.

    Establishing effective communication between healthcare professional and patient is key. This will reveal the true level of adherence, and presence of any barriers.

    The use of simple yes/no or other closed questions cannot detect and track limitations. There needs to be a deeper level of assessment. For example, structured patient interviews.

  3. Tailored health education

    Health education should to be tailored to the patient´s needs. Healthcare staff should reassure patients that information has been properly understood

    The higher the education level of patients, the more likely they will believe in their ability to actively influence their health. More support is needed to reach this attitude for participants with a lower level of education.

    While health education needs to use simple language, just providing an easy education tool will not work. Huge discrepancies can arise between what the doctor thinks his patient has understood, and what the patient thinks his clinician has told him

    “ Misunderstandings are the rule, not the exception.”

  4. Enhance sense of security

    To enhance a sense of security, families and informal carers should be routinely included in the healthcare plan or programme

    Families and informal carers are a valuable resource when helping patients with adherence. For this reason, they should be routinely included in the healthcare plan or programme. A strategy to enhance a sense of security needs to be considered.

    Support from relatives and friends is a meaningful resource to promote adherence. If more accurate information is shared, care could be more effectively managed. Feeling secure constitutes an important factor influencing the health behaviour of patients.

  5. Awareness of adherence barriers

    Frontline staff need to be aware of the barriers to patient adherence. Plus, effective strategies for its promotion. Which requires time

    To recognise details quicker, staff should be aware of adherence barriers. They should also use effective strategies for promotion. They can put more effective strategies in place if they are tailored to each patient's need. This makes it easier to provide health education. Healthcare staff should be aware that they should use dedicated strategies. This will ensure that crucial information has been processed by the patient.
  6. Single point of contact

    A single point of contact for patients, related their healthcare

    When large numbers of health professionals collaborate, it can lead to a less comprehensive view of the patient. A central point of contact can remedy this. It can be a dedicated person, or a team who deals with requests. This will avoid compromising care. It will also guard against the potential complexities of a coordinated care approach. Making it easier for patients, healthcare professionals and stakeholders to maximise the benefits.

    “ Loss of perspective can happen when too many healthcare professionals are involved in the management of the same patient and family. Resulting in the loss of coordination objectives and healthcare criteria.”


  1. Evolve assessment tools

    Evolve to an open, transparent and flexible population-based health-risk assessment tool (Table 3). This will ensure transferability among EU regions.
  2. Facilitate comparisons among region

    Facilitate comparisons among regions. Harmonise data coding, and standardise logistics for data collection and reporting.
  3. Support clinical decision making

    Assess recommended strategies. Converge population-based health risk assessment tools and individual health risk prediction modelling.


  1. Achievable data collection

    Ensure achievable data collection

    ACT recommends the agreement on a minimum dataset of outcome indicators to be collected by all CC&TH programmes. This proposal data set should be consensused and validated across Europe:

  2. Ensure data comparability

    Ensure data comparability across regions

    Address data collection challenges (comparability, ambiguity), with a small set of strictly defined indicators. For instance, following relevant standards such as HL7 Health Quality Measure Format (HQMF). This will provide the structure in which eMeasures can be defined.
  3. Facilitate local data governance

    Facilitate local data collection and governance

    The facilitation of unified data collection through interfaces, conforming to data privacy and protection legislation. Together with a distributed engine, where regions are in control of data entry to address data availability.

    Enabling access to patient level data to track adequately patient populations, and allow the optimal use of machine learning techniques and big data.

  4. Holistic evaluation approach

    Take a holistic evaluation approach

    For a holistic assessment of the programmes, not only outcomes are needed. ACT recommends:

    • Combine qualitative and quantitative indicators to provide the full picture: ACT Evaluation Framework.

    • The application of the Evaluation Engine to monitor progress of existing deployments, and the effect of changes to existing deployments.

  5. Scale assessment

    Scale the assessment of integrated care across Europe

    ACT recommends the EC to promote further initiatives in the implementation of evaluation of integrated care programmes:

    • Implementation of the recommendations to enable a continuous improvement system that would bring the required maturity level of the programmes.

    • Transfer of good practices in other regions to facilitate the faster deployment in follower systems.