Outcomes

The over-arching aim of the WP6 was to look at the best knowledge and practice today and based on that, design the features of personalised care plans for elderly patients with heart failure and the lung disease COPD. The designed care plan is expected to facilitate the patients care in a holistic way; both regarding common physical struggles but also mental, social and spiritual questions and needs. 

In this work, the WP6 collaborated with the technical partners, the health care professionals in the clinical reference groups and of course the patients and their care givers. 

A critical component of the ADLIFE toolbox is change management, ensuring it’s effectively utilised and it provides value to patients, informal caregivers, and healthcare professionals.

An early interview study within the project revealed that many patients and carers are generally satisfied with the care they receive and its organisation. However, healthcare professionals identified structural needs for enhanced coordination and integration of systems, with suggested improvements closely tied to local organisational structures and cultures. Improvement areas for digital tools like ADLIFE span all categories, with a notable emphasis on relationships: a robust multidisciplinary team familiar with the patient and their close contacts that ensures continuity of care and reduces the need for referrals.

In the first half of the project, change management was a prominent topic. WP6 work outlined five stages of change management, identified three focus areas and delivered a comprehensive change management strategy. Pilot sites were actively engaging with these change management stages and sharing their experiences.

The focus on Shared Decision-Making aimed to empower patients by embedding this approach into clinical practice, systems, processes, and workforce attitudes. Transitioning from a paternalistic model to a shared decision-making approach posed challenges but is essential for effective patient empowerment.

Support systems are crucial for successful change management. Training programs, which include informing, supporting, upskilling, and coaching activities, are integral to this effort. The ADLIFE project developed training materials, such as an introductory video and user manuals for ADLIFE components in order to support these training events.