Work Package 2: Thick descriptions of Health Network Tennengau Sociomedical Centre Liebenau WP leader: Institute for Advanced Studies (IHS), Austria WP co-leader: August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Spain Authors: Health Network Tennengau: Astrid Segert, Susanna Ulinski, Thomas Czypionka, Markus Kraus Sociomedical Centre Liebenau: Astrid Segert, Susanna Ulinski, Thomas Czypionka, Markus Kraus Date October 2016 ------------------------------------------------------------------------------------------------------------------------------------------ This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 634288. The content of this report reflects only the SELFIE groups’ views and the European Commission is not liable for any use that may be made of the information contained herein. WP2 Report: Austria Table of contents Executive Summary ...................................................................................................................................... 4 1. Methodological approach .................................................................................................................... 7 1.1. References .................................................................................................................................. 15 2. Macro level ......................................................................................................................................... 16 2.1. Service delivery .......................................................................................................................... 18 2.2. Leadership & governance........................................................................................................... 20 2.3. Workforce ................................................................................................................................... 22 2.4. Financing ..................................................................................................................................... 23 2.5. Technologies & medical products .............................................................................................. 23 2.6. Information & research .............................................................................................................. 24 2.7. References .................................................................................................................................. 25 3. Progamme 1: Health Network Tennengau (Gesundheitsnetzwerk Tennengau) ............................. 26 3.1. Basic information ....................................................................................................................... 26 3.2. Service delivery .......................................................................................................................... 28 3.2.1. Design of delivery of care ................................................................................................... 28 3.2.2. Self-management interventions ........................................................................................ 40 3.3. Leadership & governance........................................................................................................... 42 3.4. Workforce ................................................................................................................................... 46 3.5. Technologies & medical products .............................................................................................. 49 3.6. Information & research/monitoring .......................................................................................... 52 3.7. Financing ..................................................................................................................................... 57 3.8. Implementation process ............................................................................................................ 62 3.8.1. Historical information ........................................................................................................ 62 3.8.2. Present information ........................................................................................................... 70 1 WP2 Report: Austria 3.8.3. Future implementation/development .............................................................................. 70 3.9. Discussion ................................................................................................................................... 72 3.9.1. General discussion .............................................................................................................. 72 3.9.2. Discussion of the programme in the context of the conceptual framework ................... 72 3.10. Appendix – Original Quotes from Health Network Tennengau Interviews ......................... 77 3.11. References .............................................................................................................................. 88 4. Programme 2: Sociomedical Centre Liebenau (Sozialmedizinisches Zentrum Liebenau) ................ 89 4.1. Basic information ....................................................................................................................... 89 4.2. Service delivery .......................................................................................................................... 91 4.2.1. Design of delivery of care ........................................................................................................ 91 4.2.2. Self-management interventions ...................................................................................... 102 4.3. Leadership & governance......................................................................................................... 105 4.4. Workforce ................................................................................................................................. 112 4.5. Technologies & medical products ............................................................................................ 115 4.6. Information & research/monitoring ........................................................................................ 117 4.7. Financing ................................................................................................................................... 120 4.8. Implementation process .......................................................................................................... 124 4.8.1. Historical information ...................................................................................................... 124 4.8.2. Present information ......................................................................................................... 129 4.8.3. Future implementation/development ............................................................................ 129 4.9. Discussion ................................................................................................................................. 129 4.9.1. General discussion ............................................................................................................ 129 4.9.2. Discussion of the programme in the context of the conceptual framework ................. 130 4.10. Appendix – Original Quotes from Sociomedical Centre Liebenau Interviews .......................... 139 4.11. References ................................................................................................................................... 151 2 WP2 Report: Austria The SELFIE project SELFIE (Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE) is a Horizon2020 funded EU project that aims to contribute to the improvement of person-centred care for persons with multi-morbidity by proposing evidence-based, economically sustainable, integrated care programmes that stimulate cooperation across health and social care and are supported by appropriate financing and payment schemes. More specifically, SELFIE aims to: Develop a taxonomy of promising integrated care programmes for persons with multi- morbidity; Provide evidence-based advice on matching financing/payment schemes with adequate incentives to implement integrated care; Provide empirical evidence of the impact of promising integrated care on a wide range of outcomes using Multi-Criteria Decision Analysis; Develop implementation and change strategies tailored to different care settings and contexts in Europe, especially Central and Eastern Europe. SELFIE strands of research and work package (WP) overview The SELFIE consortium includes eight countries: the Netherlands (coordinator), Austria, Croatia, Germany, Hungary, Norway, Spain, and the UK. 3 WP2 Report: Austria Executive Summary Health Network Tennengau The Health Network Tennengau (HNT) is a bottom-up network comprised of social and health service providers and voluntary organisations. The Tennengau region is a rural area in the state of Salzburg. The HNT has its origins in a pilot project for medical home nursing care introduced in 1995 and has since gradually evolved into a comprehensive network. Since 2003, it has been organised as a not-for-profit cooperative that currently has 29 member institutions. Service delivery Service delivery within the programme is divided into 6 modules: (1) the core of the network, which coordinates the entire programme, (2) a counselling