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Population ageing is one of the most significant demographic and social trends of the 21st century, affecting nearly all the countries in the world (OECD, 2018). Older people are going to represent a proportionately larger share of the total population, presenting social, economic and cultural challenges to individuals, families, public welfare systems and societies. As reported in “World Population Prospect - 2015 revision” by the United Nations, between 2015 and 2030 the number of people in the world aged 60 years or over is projected to grow by 56%, and this figure is projected to more than double by 2050. Meanwhile, the ageing of the societies and other factors such as unhealthy lifestyles have resulted in a dramatic increase in chronic conditions (World Health Organization, 2002). Chronic conditions led to a spiralling demand for healthcare services with the associated costs and deterioration of patients’ quality of life.
In this context the integrated care for the frail elderly people with chronic diseases has taken centre stage among policymakers, planners and providers in several countries (Bergman et al., 1997; Glasgow et al., 2008; Vedel, Monette, Beland, Monette & Bergman 2011; Wilson, Baines, Cornford & Martin, 2007). Several systematic reviews (Eklund & Wilhelmson, 2009; Ouwens, Wollersheim, Hermens, Hulsher & Grol, 2005) have been published on the integrated care or disease management programmes for different chronic patient groups. In this field ICT tools could play a key role in better integration of healthcare and social needs (Lluch & Abadie, 2013; Melchiorre et al., 2018).