Purpose The fragmented delivery of health and social services for large groups of patients with chronic conditions was put on the research agenda in 2002 by WHO. The FP7-IHC-project ( http://www.integratedhomecare.eu/ ) aims to develop a turn-key-solution for better clinical continuity to European health regions. Method Systematic review of the literature on clinical continuity as complemented by trials and surveys within this project. Preliminary results 1. Integrated home care (IHC) is the most promising approach to better clinical continuity from the point of view of cost-effectiveness. IHC is characterized by 1) delivery form, 2) funding/administration, 3) organization and 4) clinical focus. 2. Stroke, COPD and heart failure (HF) are diseases of first priority regarding IHC with Poor-outcomes as a common indicator of efficacy. Alone, for these 3 chronic diseases give more than 1 million new patients per year in EU might benefit from IHC. 3. As IHC improves activities of daily living (ADL) which implicates long term savings in social care services the working hypothesis is that IHC is a health economic dominant intervention. This enables a meso-strategy of dissemination focusing European health regions with direct contact between clinical and funding levels instead of national legislative levels. 4. The practical efficacy of IHC is closely related to the combination of patient-centric procedures with multidisciplinary expertise across administrative sectors. 5. Barriers in funding across sectors and over time slow down implementation wherefore a special study of these problems and their solution is ongoing specific to each EU-country.
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<strong>World Conference for Neurorehabilitation</strong>, 2010