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.

JACARDI’s voices on the scientific stage across Europe

The first half of 2025 has been a busy and productive time for JACARDI, with consortium members sharing key findings and pilot implementation highlights at leading scientific conferences across Europe. These contributions, spanning health literacy, integrated care, biomarker-based screening, and health economics, demonstrate the depth and scope of the work underway across multiple work packages.

Spotlight on ICIC25 – Lisbon, Portugal | May 14–16, 2025

JACARDI had a strong presence at the 25th International Conference on Integrated Care (ICIC25) with three distinct contributions representing different work packages:

Irati Erreguerena (Work Package 6 – Health literacy) delivered an oral presentation on a co-designed health literacy program for adolescents in the Basque Country, Spain. Her talk highlighted how WHO’s Health Literacy Development Model, and the Ophelia (Optimising Health Literacy and Access) co-design methodology were applied to empower younger populations with knowledge and tools for chronic disease prevention.

Yhasmine Hamu (Work Package 9 – Integrated care pathways) presented on the implementation of a value-based integrated care model, sharing strategies to address care fragmentation and improve outcomes for people with chronic conditions.

Gergely Varga (Representing both Work Package 9 – Integrated care pathways and Work Package 5 – Methodological framework) contributed a poster that outlined a situational analysis methodology designed to support integrated care.

Faculty of Public Health Summer Scientific Meeting – Dublin, Ireland | May 20–21, 2025

Sonja Moore (Work Package 8 – Screening) presented findings from a scoping literature review on the use of natriuretic peptides in cardiovascular risk stratification and management. Her poster focused on current strategies and approaches for using these biomarkers in patient populations without diagnosed heart failure, a topic gaining traction in preventive cardiology. The review aimed to inform more targeted screening protocols and identify gaps in clinical practice across Europe.

COMET Conference – Poznań, Poland | June 25–27, 2025

Richard Osborne (Work Package 6 – Health Literacy) represented JACARDI at the 23rd International and Interdisciplinary Conference on Communication, Medicine, and Ethics (COMET). His oral presentation focused on scaling up health literacy development as a strategy to prevent and manage non-communicable diseases. The talk stressed the need for strategic investment in communication and co-design at the system level.

1st European Public Health Economics Conference
– Palermo, Italy | June 26–27, 2025

Katie Ellwood (Work Package 8 – Screening) presented a pilot study from JACARDI aiming to establish the most cost-effective threshold for using NT-proBNP blood marker in cardiovascular disease (CVD) risk stratification. The analysis models the impact of different thresholds over a 30-year horizon in a large population cohort. This pioneering work within JACARDI bridges clinical practice with health economics, helping to inform sustainable, evidence-based screening strategies.

These scientific initiatives reflect JACARDI’s commitment to knowledge-sharing, collaboration, and measurable impact. Consortium members not only showcased research but also engaged with policymakers, practitioners, and academics, advancing the mission to improve cardiovascular and diabetes outcomes across Europe. The autumn season offers a variety of relevant conferences, kicking off right at the end of summer with the Congress of the European Society of Cardiology, taking place from 29 August to 1 September.