Abstract
The progressive aging of the population, together with a higher incidence of chronic diseases and the rise of technological innovations, have led to an increase in health and social care needs, affecting the sustainability of healthcare systems around the world. European healthcare systems are transforming the traditional model of care based on volume and productivity amidst fragmented care services, towards value-based care models that guarantee an optimal use of resources and better health outcomes in the population served. With this scope, ValueCare is an European project providing comprehensive, integrated and personalised care that combines medical and social prescription, achieving better health outcomes. ValueCare is addressed to improve the quality of life of older people and those that formal or informal take care of them. ValueCare pathways has been co-designed and validated with older people and their care team, putting in the center older people decisions. Specifically, for the Valencia Pilot, 120 older people (>65 years old) with mild to moderate frailty and their families and professional care team participated in the validation phase. For the recruitment process, health and social professionals identified patients who could be potential participants. They performed validated questionnaires to determine the level of frailty (Frail), dependency (Barthel) or cognitive impairment (Pfeiffer) and those who met the inclusion criteria were included. Once involved, a comprehensive evaluation of the participants’ health was made using the ICHOM set for older people together with extra validated questionnaires related to frailty and focused on: physical activity, nutrition, adherence to medication and psychosocial prescription. According to the results of this baseline evaluation and through a co-design process, the health and social professionals and the project researchers, together with participants, developed a personalised care plan, based on the specific needs and interests of each participant. Within the personalised care plan, older people and their care team established specific objectives to address their particular needs based on the mentioned 4 areas. The objectives were integrated into a digital solution developed during the project to facilitate patients’ compliance and enable social and health professionals to follow-up the process of the intervention from an integrated point of view. Focused on the physical activity area, a series of weekly goals were seat for each older person to improve their level of frailty based on exercises and physical activities adapted to each individual's abilities and social and health needs. The care team proposed activities developed in the participants' neighbourhood to also contribute to alleviate their social isolation and contribute to building community (social prescription). Additionally, patients attended a series of workshops on active and healthy ageing from which the ""ValueCare community"" was created to share experiences and good advice related to the area of physical activity. The involvement of patients in the ValueCare project and therefore the fulfilment of specific objectives and the attendance of these workshops, motivates and empowers them to make a behavioural change towards healthy habits to improve their physical capacity and ultimately their health and wellbeing.