Objectives

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

In the work package we will ask how the existing health care services are experienced, and what can be done better or in another way.

In the personalized care plans patients and health care professionals will work together and decide on what goals and activities that are suitable for the chosen patient. Both patients, their informal care givers and the health care staff are important stakeholders in this work, as they all will work together in a coordinated way. 

Another task for the WP6 is to define what clinical guidelines will be used to give the health care professionals advise and support in decisions at different levels.

This tool will help the clinicians in their work. Each pilot site will have a clinical reference group that will assess the final rules and algorithms to ensure that they support assessment and treatment of the patients’ changing situation. 

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

Most of the work of WP6 will be done in the very beginning of the ADLIFE project as it is the basis for the tools to be developed.