Actors and their roles Sample Clauses

Actors and their roles. The pathways involve a number of different stakeholders or actors, including individuals and organisations either receiving or delivering the service based on the pathway. The following tables provide an overview of the different actors and a description of their role. Differences between the two pathways are highlighted, with elements referring only to the short-term care pathway being marked as “ ICP-Short ”, and elements referring to the long-term care pathway as “ ICP-LTCare ”. Elements not specifically marked apply to both pathways.
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Actors and their roles. The pathways involve a number of different stakeholders or actors, including individuals and organisations either receiving or delivering the service based on the pathway. The following tables provide an overview of the different actors and a description of their role. Campania is the only pilot site where there is, apart from the length of service provision, no difference between the two generic pathways in terms of services provided, providers involved and processes of care service delivery. Therefore, no distinction between both pathways is made in the following tables. Description of actor characteristics End users of the services developed under BeyondSilos. Profile: • Elderly people living at home (65+). • In a frail situation regarding social and/or health needs. • Enrolled in the Project due to chronic situation regarding Health &Social needs. The process of enrolment is triggered directly by AUIC, by the University Hospitals, or by the ASL clinics, GPs or social carers. After the referral and enrolment process, CRs will be monitored by the home care services provided by the ADI, including health and social care (medication, physiotherapy, hygiene, food, home cleaning). CR will stay in the process as long as they need home care support. After that they will be dis-enrolled. AUIC usually re-evaluates cases monthly.
Sample 1
Actors and their roles. The pathways involve a number of different stakeholders or actors, including individuals and organisations either receiving or delivering the service based on the pathway. The following tables provide an overview of the different actors and a description of their role. Kinzigtal is another pilot site where there is, apart from the length of service provision, no difference between the two generic pathways in terms of services provided, providers involved and processes of care service delivery. Therefore, no distinction between both pathways is made in the following tables.
Sample 1
Actors and their roles. The pathways involve a number of different stakeholders or actors, including individuals and organisations either receiving or delivering the service based on the pathway. The following tables provide an overview of the different actors and a description of their role. Since actors are similar for both pathways in relation to their basic characteristics, their role in the service, and information handled, no distinction between both pathways is made in the following tables. Description of actor characteristics Frail elderly and those with long-term conditions living in their own home or in a homecare setting. For TNI service, LTC are COPD, CHF/CHD, diabetes and post stroke / TIA and clients in receipt of a telecare service. From eNISAT, any patient or client for whom an eNISAT assessment is completed. For Integrated Care Plan, following risk stratification of patients in a GP practice, initially the top 15 patients by risk. CR may fall into either or both of the above. Description of role in service delivery / utilisation CRs will be consumers of the health and social care services. They will be referred to the TNI service and/or be subject to an eNISAT assessment, and/or have an Integrated Care Plan completed in the NIECR. They will have no access to view the ECR. Information handled in the context of service delivery / utilisation For citizens on the TNI service: • Telehealth: xxxxx xxxxx information collected by the system will become available for all appropriate health and social care personnel to view from the ECR. This may include (dependent on condition being monitored) blood pressure, blood glucose, SPO2, weight, pulse, temperature, ECG. Actual readings and track and trend information will be available. • Telecare: details of any alarms or events will become viewable from the ECR. • eNisat: details of any of the relevant sections will become viewable from the ECR: • Core screening. • Core assessment. • Complex assessment. • Carer needs assessment. • Specialist referral. • Specialist summary. • GP report. The Integrated Care Plan within the NIECR will detail the patient’s personal Care Plan; this will detail: • Summary of significant medical conditions. • Current medication and allergies including date of last medication review. • Pharmacy information. • Community team involvement, including named staff and if patient is in receipt of telemonitoring service. • Disease specific care plans. • Review of hospital admissions and ED attendances in past y...
Sample 1

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