Urbani izziv, thematic issue, 2015, no. 1
81Presentations and information
Natalia ALLEGRETTI
NATHCARE: Networking Alpine health  
for continuity of care
Duration: 1 September 2012 – 30 June 2015 (34 months)
Financing
The project is co-funded by the Alpine Space Programme:
• Total project costs: €2,753,000
• Total ERDF funds: €1,926,600
Project starting points
Demographic change is a global trend 
in Europe that particularly affects the 
Alps. The age index, showing the ratio 
between older people (those over sixty-
four) and younger people (those under 
fourteen), reveals the dramatic extent 
of this problem, which is primarily the 
result of young people moving to nearby 
towns and cities for better employment 
opportunities. In the framework of a 
changing society, there is a need for spe-
cific political activities able to respond 
to new needs. Within the healthcare 
sector, the rising number of elderly 
can be easily translated into significant 
growth in the number of patients with 
long co-morbidities, as well as a wider 
range of age-related conditions. From a 
recent European study, about 80% of 
older adults have one chronic or long-
term condition, and 50% at least two. 
Another dimension of this trend is the 
increasing number of women delaying 
motherhood: this causes more clinical 
risks and complications that require co-
ordinated social and clinical services for 
taking care of woman. From such a per-
spective, the need to reduce the burden 
of increasingly older populations poses 
a common challenge for healthcare 
systems in the Alpine area and quality 
performance across care settings. Vari-
ous forms of healthcare able to deliver 
better health to a changing population 
but, at the same time, able to support 
sustainable and efficient care systems, 
are needed. Organisational innovation 
supported by technology provides ways 
to best tailor care services both to the 
growing demand linked to ageing and 
to long-term expansion of diseases, and 
to offer the same level of services as in 
metropolitan areas to encourage resi-
dents to remain in the Alps. The main 
drive should be a move towards an in-
tegrated social and healthcare model 
fostering the concept of collaborative 
activities between hospitals and areas 
to support continuity of care and over-
come fragmented interventions. Future 
healthcare systems thus need to deliver 
high-quality care while using cost-effec-
tive models.
Project purpose, objectives and content
Addressing a health-related condition – 
be it an acute or long-term disease – in 
modern healthcare systems requires the 
involvement of multiple professionals, 
each of them focusing on a facet of an 
intricate picture that needs integrated 
management. The need for more ef-
ficient ways to integrate and circulate 
both knowledge and clinical informa-
tion among all participants during care 
is high and often unaddressed in the 
modern healthcare system.
NATHCARE’s main goal is to provide 
ICT solutions addressing this problem 
and also to ensure that remote areas may 
enjoy the same opportunities as metro-
politan areas as far as health is con-
cerned. NATHCARE has designed and 
consolidated, and is validating, a model 
embracing all players in the system for 
securing economic sustainability and 
improved organisational adaptation of 
healthcare services. The proposed mod-
el, starting from the regional healthcare 
systems involved, analyses the process 
for appropriate hospital territory inte-
gration by mainly, but not exclusively, 
addressing long-term diseases from the 
perspective of continuity of care as a 
dimension of demographic change.
A central role in the project is played by 
“local healthcare communities”, which 
represent the physical and organisation-
al localisation of NATHCARE service 
experimentation. Each local communi-
ty, nine in total, is identified according 
to the specific healthcare model in use 
at the regional level and is envisaged as 
networking all the stakeholders  – pa-
tients, hospital-based healthcare pro-
fessionals and territory-based healthcare 
professionals  – involved in long-term 
care management.
The project strategy aims to promote 
exchanges of evidence-based infor-
mation on best-practice and state-of-
the-art management of health-related 
conditions starting with long-term dis-
eases; supporting the implementation 
Urbani izziv, thematic issue, 2015, no. 1
82 Presentations and information
of best practices described above at the 
NATHCARE pilot site level through 
the use of ICT tools and an innovative 
organisational approach; empowering 
patient profiling and identification for 
sharing over the entire NATHCARE 
consortium guaranteeing patients de-
served treatment regardless of their 
location.
The NATHCARE approach was con-
ceived taking into account that most 
healthcare systems target chronic con-
ditions, implementing a “traditional” 
disease-care model that is mostly physi-
cian-centred, episodic, strongly focused 
on acute care and reactive rather than 
proactive. Modern healthcare systems 
are struggling with the commitment to 
develop new care models, overcoming 
some inadequacy of “traditional” ap-
proaches, designing models that should 
be patient-centred, integrated and pro-
active with care delivered by a health-
care team. This means that, to ensure 
an adequate response from health sys-
tems for this dimension of demographic 
change, measures such those listed be-
low should be implemented:
•	 Better coordination of care across 
health and social services, as well 
as across different levels of health 
care, is seen as crucial;
•	 Because many older people inap-
propriately remain in hospital, a 
number of measures can be ap-
plied to allow for more treatments 
out of hospital;
•	 Encouraging better self-care: in-
creased health literacy and better 
access to technology, such as com-
puters and the internet, may help 
improve the understanding and 
management of specific diseases.
Such measures have been taken into full 
account by the NATHCARE project 
in developing a “management solution 
for long-term care patients” through a 
three-pronged strategy: 1)  Integration 
of primary care: integration of primary 
and secondary healthcare processes to 
establish an up-to-date patient care 
plan. This is intended to support the im-
plementation of a patient-centred, coor-
dinated care model, targeting patients 
requiring continuous and coordinated 
care, 2) Knowledge management: aimed 
at capitalising the professional compe-
tencies present in the NATHCARE 
network, making them available to all 
professionals and organisations. The fi-
nal goal is to improve the level of service 
towards the highest standard available 
and to promote cooperation among 
centres participating in NATHCARE, 
3)  Patient empowerment: this is an es-
sential part of NATHCARE focused 
on increasing awareness and promoting 
healthy lifestyles.
A coordinated care model simplifies the 
dialogue between different providers of 
healthcare services involved in caring 
for patients affected by chronic condi-
tions and co-morbidities, such as elderly 
patients. This makes coordinating care 
across various levels of healthcare par-
ticularly important (integration rather 
than fragmentation). Better coordina-
tion and a greater emphasis on preven-
tive services are advocated as a way to 
reduce hospital admissions and length 
of stay. With this has come a shift to-
wards care and treatment moving out 
of the hospitals and into the commu-
nity and the home, leaving patients and 
family with a greater responsibility for 
their own health. In line with this health 
transition, the focus on patient respon-
sibilities and their role in managing 
their health has grown substantially and 
is an increasing focus of health policy. 
Empowering patients means providing 
them with the opportunities and the 
environment to develop the skills, con-
fidence and knowledge to move from 
being passive recipients of care to active 
partners in their healthcare. To do so, 
information needs to be much more 
easily available and understandable; in-
creased health literacy and better access 
to technology, such as computers and 
the internet, may help patients engage 
more in self-care. More structured ac-
cess to knowledge promoting exchange 
of evidence-based information about 
best-practice and state-of-the-art man-
agement of health conditions will sup-
port healthcare professionals in deliver-
ing better care and in becoming more 
effective communicators.
The technical development of the model 
led to deployment of the NATHCARE 
system, allowing the start of the project 
pilot phase. The results of the model 
evaluation as implemented and used in 
real environments during the project 
testing phase, benchmarked with chron-
ic disease management models currently 
adopted, will be offered to policymak-
ers as an example for inspiration for 
adopting orchestrated policy strategies 
to mitigate the impact of demographic 
change on healthcare systems.
Work package content
The project is divided into eight work 
packages. Each work package is divided 
into a number of actions. 
The project work packages:
•	 WP1: Project Preparation: Project 
proposal preparation.
•	 WP2: Project Management: Pro-
ject management including con-
tent coordination and financial 
and economic management.
•	 WP3: Information and Public-
ity: Dissemination and awareness 
creation about the project and its 
results.
•	 WP4: User Requirements: Analysis 
of users’ needs and requirements. 
Definition of the system’s func-
tional specifications.
•	 WP5: Model Design: Description 
of the NATHCARE model, which 
proposes a common, overarching 
architecture, which takes into ac-
count the diversity of regional im-
plementations. Definition of the 
legal, technical and organisational 
rules to be applied to model imple-
mentation and operation.
Urbani izziv, thematic issue, 2015, no. 1
83Presentations and information
•	 WP6: Services and Platform De-
sign: Technical design, devel-
opment and integration of the 
NATHCARE platform and ser-
vices devoted to support the re-
gions involved to best cope with 
dimensions addressed by the 
project as part of demographic 
change.
•	 WP7: Testing and Piloting: Imple-
menting the NATHCARE system 
at pilot sites, training and pilot op-
erational activities.
•	 WP8: Assessment: Analysis and 
assessment of current healthcare 
models devoted to continuity of 
care in partner regions. Evaluation 
and assessment of the NATH-
CARE model. Definition of the 
NATHCARE reference frame-
work to be used at the political 
level as a reference for conceptu-
alising policy guidelines.
Project results
The project has achieved relevant inter-
mediate results, including:
•	 An analysis of the functional, 
technical, organisational and le-
gal requirements conducted at 
the level of hospitals, healthcare 
organisations and professionals 
aimed at mapping current ways to 
manage chronic and long-term pa-
tients, and also identifying major 
elements for improvement of the 
chronic-disease and long-term-
care management process.
•	 Definition of the functional and 
non-functional requisites shaping 
the NATHCARE model, which 
provides a set of ICT-based servic-
es integrating primary and second-
ary care, knowledge management 
and patient empowerment.
•	 A model conceived as a modu-
lar system composed of building 
blocks that can be customised 
according to three different sce-
narios for implementation: 1)  a 
standalone solution, which was 
completely developed by the 
NATHCARE technical team, 
2) an integrated solution, in which 
components of the NATHCARE 
standalone solution are replaced 
by components that are available 
at the pilot site, or 3) an organisa-
tion’s own application, in which an 
already-existing solution is in place 
and is integrated with a knowledge 
management tool developed with-
in the project.
•	 A network of nine local health-
care communities, geographically 
consistent, regionally based and 
qualified in each territory in the 
light of healthcare responsibilities 
and professionals’ roles, gathering 
all the players in the care system 
to localise the pilot actions and 
to test and validate the NATH-
CARE model.
•	 A complete system prototype 
composed by two dedicated ap-
plication modules: the Knowledge 
Management Tool and the Care 
Plan Tool. The NATHCARE sys-
tem user interface (the main point 
of access to all NATHCARE ser-
vices by system users) has been 
conceived to be as user-friendly as 
possible to facilitate use of the ap-
plication and to create a pleasant 
and agreeable “look and feel” of 
the overall system. Deploying the 
system has allowed the start of the 
project pilot phase with different 
timing.
•	 A defined methodological ap-
proach and related indicators for 
assessing both current healthcare 
models and the NATHCARE 
model. The effectiveness of the 
proposed NATHCARE model 
will be measured starting from 
an in-depth analysis of current 
healthcare models applied in 
each piloting region for managing 
chronic and long-care term condi-
tions, in order to understand the 
extent to which the NATHCARE 
model can improve them.
•	 A preliminary policy guideline 
providing an initial view of the 
lessons learned through imple-
menting the project activities and 
outlining the initial results that 
the project team can offer stake-
holders for further reflection.
Project partners
NATHCARE has a geographical cover-
age including nine regions in the Alpine 
area and is coordinated by a consortium 
composed by regional institutions in 
charge of healthcare and eHealth gov-
ernance and policy implementation, 
healthcare organisations and hospitals, 
and competence centres combining 
technical and clinical skills.
The NATHCARE project partners are:
•	 Lombardy Region: General Di-
rectorate for Health (Italy), lead 
partner
•	 INSIEL s.p.a, RDT European Pro-
jects (Italy)
•	 Autonomous Province of Trento, 
Local Ministry of Health and 
Healthcare Policies, Department 
of Health Policies (Italy)
•	 Garmisch-Partenkirchen Hospital 
(Germany)
•	 Healthcare Cooperating Group, 
Rhône-Alpes Information System 
for Healthcare (France)
•	 Rhône-Alps Regional Oncology 
Network (France)
•	 Healthcare Cooperating Group, 
EMOSIST, FC (France)
•	 INSA, LIRIS, IT Department 
(France)
•	 Villach Regional Hospital (Aus-
tria)
•	 Golnik University Clinic of Pul-
monary and Allergic Diseases 
(Slovenia)
•	 Geneva University Hospitals 
(Switzerland)
Natalia Allegretti 
Lombardia Informatica s.p.a, Milan, Italy 
E-mail: natalia.allegretti@cnt.lispa.it