The array of health, social care and housing services, and their benefits and procedures can be confusing, particularly for people who are older and live with one or more chronic condition.

Although the provision of collaborative service models bringing together the usual silos of social care, health care and informal support have started to emerge in some regions in Europe, much remains to be done to deliver truly integrated care which meets people’s needs.

BeyondSilos aims at further spreading ICT-enabled, joined-up health and social care for older people by developing, piloting and evaluating integrated services based on two generic pathways in a multicentric approach, making extensive use of knowledge and experience gained among early adopters of integrated eCare in Europe. Third sector organisations and family/informal carers, where appropriate, are included in the information loop in order to facilitate service users to self-care and live independently.

...for two care settings using innovative technologies to facilitate the collection and sharing of information.

• Integrated short-term home support after an acute episode
• Integrated long-term home support.

The first pathway addresses the need for joined-up home support arising from an older person experiencing an acute hospital episode or deterioration in their health and wellbeing and the immediate support at home afterwards, e.g. after a hospital discharge or a fall. All the processes, services, information, and communication required to ensure service users receive appropriate treatment, rehabilitation and independent living enablement services at home after an acute episode are part of this pathway.

The second pathway is designed to provide integrated and coordinated services for people living at home and who have complex needs which require a flexible approach to both health and social care support to
reflect the expected fluctuations in an individual’s health and wellbeing over time.

Each pilot site is engaging with a wide range of stakeholders, including service users and their carers. The project will develop approaches to implement and evaluate both generic pathways within their system of health and social care delivery, including the third sector and family/informal carers wherever relevant.

BeyondSilos began in February 2014 and is expected to run until January 2017. The project has a total volume of 5.47 m €, half of which is co-funded by the European Commission under the framework of its Competitiveness and Innovation Programme (CIP, grant agreement no. 621069). The project brings together 13 partners, including service providers, IT providers, researchers and consultants. Integrated services will be implemented and piloted in the regions of Northern Ireland, Sofia in Bulgaria, Badalona and Valencia in Spain, Campania in Italy, Amadora in Portugal and the Kinzigtal in Germany. The pilot sites will follow a common programme for service development and implementation that specifically takes into account the requirements of users and care professionals, of service providers and business experts. An evaluation programme for the pilots will be developed by the Odense University Hospital, be based on the MAST methodology for the evaluation of complex interventions. With a view to the development of economically viable service models, the pilot regions will be supported by project partner empirica with a dedicated approach for business case modelling, called ASSIST - Assessment and evaluation tools for e-service deployment in health, care and ageing. The project is co-ordinated by the Health and Social Care Board (HSCB), Northern Ireland with support from HIM SA, Belgium.