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The White Paper of the project

July 06, 2016

The ASSEHS project has a specific work package (WP7, led by Telbios) whose purpose is to analyse the deployment of stratification techniques and implementation of integrated interventions targeting frail complex chronic patients in several sites: Basque Country, Catalonia, Lombardy, Puglia. Even if all four of these regions belong to Mediterranean countries (thus their health systems share some common features, such as being publicly funded), the organization of healthcare in these regions is sufficiently heterogeneous to ensure that the findings of this analysis are generalizable also to other regions.


Work package 7 developed a framework ( Intervention Assessment Framework - IAF) which incorporated all the findings from the other ASSEHS work packages and which was used to assess the ongoing initiatives using stratification in the different regions. The IAF encompasses all the domains involved in risk stratification: a) the selection or development of a risk stratification tool, b) the implementation plan for a risk stratification tool, and c) the impact of the deployment of a risk stratification tool.


Bottom line, the IAF generated is a heterogeneous set of tools, which can be used to assess Regional interventions based on risk stratification. Each tool was targeting different profiles, from risk stratification tool developers, to programme managers, to clinicians, to commissioners, to key informants, etc. Eventually, the full framework generated more than 80 indicators in the three areas mentioned above, and the final list of tools (each of which might span through multiple domains) resulted in:

  • 2 surveys (one on the selection/development of risk stratification tools and one on the satisfaction of clinicians)
  • 3 interviews (one on the selection/development of risk stratification tools, one on implementation, and one on funding)
  • 1 focus group (on barriers and facilitators for the implementation and deployment of risk stratification tools)
  • A data collection methodology from Regional Databases

Through the deployment of the IAF in each Region and the analysis of the generated data, it was possible to gather an insight on each Regional programme, highlighting the improvement areas and extracting the good practices that could be replicated in other Regions approaching stratification.


The final output of WP7, which is also the final output of the ASSEHS project, is a White Paper, which was released at the end of June 2016. The goal of this White Paper is to spread knowledge about the use of risk stratification tools at policy making, healthcare management and clinical practice levels. The White Paper describes in detail the main barriers which can be encountered when planning and deploying risk stratification tools in a regional intervention, as well as the facilitators that will help to overcome those barriers, and concrete examples of implementation from the four pilot regions.


The best practices and lessons learnt from those pilots are supposed to serve as examples for the development of programmes for managing multi-morbidity among complex frail older citizens, and to help policy makers and stakeholders to design, plan, deploy and validate risk stratification in other Regions.


The goal is that this White Paper will support other Regions and healthcare systems in the transformation towards new models of provisioning of proactive and targeted interventions according to the patients' needs.

Click here to download the White Paper. 

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This webpage arises from the project ASSEHS which has received funding from the European Union, in the framework of the Health Programme (2008-2013).