A major step forward: Basque country rolls out integrated heart failure care model

A new pilot project has recently been launched in the Basque country as part of JACARDI, featuring an integrated, value-based care pathway for people with heart failure. This pilot is aligned with JACARDI’s broader mission to reduce the burden of cardiovascular disease and diabetes across Europe by strengthening coordinated care, enhancing health literacy, and scaling best practices. 

Within JACARDI, Biosistemak represents the Basque country as an affiliated entity, co-leading communication and dissemination activities, supporting methodological frameworks for European pilots, contributing to health literacy initiatives, and leading the deployment of the heart failure pathway. This includes conducting a comprehensive needs assessment on the European level.

On 27 November, at the launch event organized at Cruces University Hospital in Barakaldo, Osakidetza – the public health care service of the Basque country – presented the new value-based integrated care pathway for heart failure, after two years of joint development with Biosistemak and Osakidetza’s Care Integration and Chronicity Service (SIAC). Throughout the entire development process, Biosistemak provided methodological support on pathway design, including the adaptation of care pathways and resources, the development of evaluation frameworks, the integration of technological requirements, and the preparation of awareness raising actions and training plans for professionals. The result is a comprehensive and coordinated care model that improves outcomes and quality of life for people living with heart failure while ensuring long-term sustainability.

During the event, Biosistemak researcher Yhasmine Hamu highlighted the importance of the extensive multidisciplinary collaboration behind the initiative. Over two years, professionals from family and community medicine, hospital care, nursing, pharmacy, and management collaborated to create a model that responds to real patient needs and incorporates sex- and gender-based perspectives. Presentations also highlighted innovative solutions, new corporate tools, and lessons learned on improving communication, standardising care, and defining indicators for continuous improvement.

The jointly developed pathway covers the entire care cycle for people with heart failure, from initial suspicion of the condition to hospitalisation, discharge, and ongoing follow-up in both primary and specialised settings. It is designed to align the perspectives of patients, professionals, and the general population. For patients, the model organises interventions and responsibilities in one integrated system to reduce morbidity and mortality and strengthen self-care. For professionals, it offers a clear overview of actions to be taken, decision-support tools, and a framework that promotes coordination and reduces variability. On a societal level, the model improves population health by enhancing scientific knowledge and reinforcing the sustainability of health systems.

The success of this pilot is a perfect example of how JACARDI supports Member States in adopting evidence-based and scalable care models for chronic disease management. Through its leadership in this initiative, Biosistemak contributes to strengthening integrated care and advancing cardiovascular health both within the Basque country and across Europe.