Prioridad proyecto 27: 3 - Promoting social cohesion and territorial and demographic balance in Sudoe through social innovation, heritage enhancement and services

This strategy, which covers GT1 and GT2, aims to improve the model of care for elderly patients both in hospital and in the transition to primary care through the implementation of an individualised training program and the promotion of healthy habits.Through the development of an eHealth tool will favor the promotion of habits for a healthy and active aging, also facilitating communication between medical and patient/family personnel. GT1: the strategy will include the joint development of the new hospital care model to prevent the onset of disability generated during the hospitalisation period and improve the quality of life of the patient, optimising resources.This new model will include the key points to take into account in each hospital to increase its impact: greater efficiency in the allocation of health resources, improvement of the quality of life of hospitalised elderly people, as well as of families reducing their dependence on people who care for them.This will reduce the institutionalisation of patients in residences to obtain adequate care favoring the family environment. GT2: the strategy will include the joint development of the new model of patient care in its transition to primary care or that goes to consultation (without previous hospitalisation), in order to prevent the onset of disability as a result of hospitalisation or generated by the aging itself. This new model will include the key points to be taken into account in each region and in each health system in order to increase the social and economic impact of both health systems and patients. Thus, through the strategy and its action plan, equal access to a clinical intervention with proven results will be favored, reducing the differences in hospital care between the different territories, decreasing resources related to health.

To promote the replication of the experience in other rural areas of Spain, France and Portugal, the project will develop a strategy for the activation of regional agents for the provision of advanced clinical services and a guide for the promotion of public policies by the competent local and regional authorities, trying to promote a public-private collaboration so that these ecosystems of clinical care and neuro-rehabilitation face-to-face and remote develop sustainably in other rural areas of the SUDOE territory.