This document summarizes a project that coordinated telemonitoring and telecare for chronic patients in the Basque region of Spain. The project integrated health and social care to customize support for each patient's needs and improved health outcomes, quality of life, and satisfaction for patients, families, and caregivers. It also increased efficiency by standardizing services and reducing healthcare resource use and professionals' workloads. The conclusions were that coordinating health and social care not only improved patient health but also increased satisfaction while achieving less use of health resources and a streamlined workload for health workers.

1. INTRODUCTION
The socio-healthcare
integrated collaboration has
enabled the care being
provided to adapt and to be
customised to the socio-
healthcare requirements of
patients with an individual
focus through a coordinated
and multidisciplinary
interaction of all the agents
members of the project.
The use of these synergies
and this multidisciplinary
interaction has allowed the
exploitation of resources,
enhancing the capabilities
and structures already in
place thus rendering it
unnecessary to create new
capabilities or expand the
current portfolio of services.
An example of this is the way
in which it draws on the
experience of telecare in
care and management of
technological devices in the
home, offering a
comprehensive vision of the
individual, and placing
people at the centre of the
system and rationalising the
use of resources.
It has also helped standardise
the telecare and
telemonitoring services in a
natural manner without
affecting the organisations
involved.
RESULTS
We can therefore
conclude that the project has
allowed:
• An improvement in the
health, quality of life,
satisfaction, self-management
of their disease and safety of
patients.
• An improvement in the
satisfaction and safety,
quality of life, safety of the
caregivers and family.
• An improvement in the
satisfaction and
standardisation of the
workload of the health
professionals involved.
• Promotion of socio-
healthcare collaboration,
using structures and services
that are already in place,
making the model sustainable
and cost effective.
• A provision of
management of the social
profile of the individual to
classic telemonitoring models
and projects already in place
through coordination with
traditional telecare.
BASQUE TELECARE CENTRE*
TELBIL+T: TELEMONITORING AND TELECARE
IN CHRONIC ILLNESSES
ABSTRACT
The project TELBIL+T
coordinates
telemonitoring and
telecare within the
same system, using
a protocol, involving
coordinated action
between Primary
Health Care, Public
Telecare Service
(betiON), the Health
Council and the
Emergency Services
of the Santa Marina
Hospital for chronic
patients with heart
failure and/or lung
disease. Between
December 2012 and
November 2014 with
75 patients who,
owing to their level
of dependency,
were users of
betiON.

2. B A S Q U E T E L E C A R E C E N T R E
• A provision of a base for
the elaboration of a shared
socio-healthcare history.
• A provision of the keys
for the standardisation and
extension of telemonitoring in
the follow-up of complex
multipathological patients.
• A demonstration of the
importance of primary care,
from a healthcare point of
view, in the care of people for
an early intervention thus
preventing subsequent high
hospital bills.
DISCUSSION
The TELBIL+T project
complies with the objectives
established when it was
initiated. Not only has this
demonstrated an
improvement of the health of
the patients recruited but it
has also permitted the
increase in their satisfaction
and quality of life as well as
that of their families and
caregivers. The project
facilitates and promotes the
empowerment of patients
and their environment by
improving their autonomy
and management of their
illness. All this is tied in with the
low usage of healthcare
resources, both in terms of
admissions, average length of
stay and hospital emergency
departments as well as visits
made to health centres. This
has resulted in a
rationalisation of the workload
of healthcare professionals in
the majority of cases, focusing
their actions solely on
healthcare interventions
when and where necessary.
The project has been well
accepted by the socio-
healthcare professionals
involved, according to the
input received during the
evaluation of the project.
*BASQUE TELECARE CENTRE. Public Telecare Service. Employment & Social Services
Department. Basque Government
Email addres: aalday@osatek.eus
The full version of this study is published by the Caser Foundation and can be accessed at the
following link: http://www.fundacioncaser.es/sites/default/files/telbilt_j.garcia_web.pdf
CONCLUSIONS
Health and social care coordination not only demonstrated improved health of patients
received but also made it possible to increase their satisfaction and quality of life as well
as that of their families and caregivers. Furthermore, less use of health resources was
achieved, related to both hospital and primary care, leading, in most cases, to a
streamlining of the workload of health workers, focusing their activities solely on health
interventions when and where they were needed.