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AND PROJECT DISIGN: In the randomized clinical trial “TELBIL study”(1) elderly patients with advanced chronic diseases and comorbidities were telemonitored from Primary Care. At 1 and 2-year follow-up, the outcomes indicated a reduction in hospital admissions and stay, better health related quality of life (HRQL) and functionality, and also good acceptance, satisfaction and compliance with the protocol and technology, without a higher cost than usual care. The “TELBIL-A project”* is a continuation of this previous study at the local Primary Health Care organization, but with AN IMPROVED DESIGN AND INTERVENTION: • More individualized telemonitoring content, according to patient characteristics and different situations we came across. In addition to heart failure and/or pulmonary diseases, patients with other chronic conditions and multimorbidity can be included; and we also consider temporary telemonitoring situations. • Strengthening the role of primary care, especially that of the nurses.

Continuing experience and research on a home telemonitoring intervention of chronic-pluripathological patients, “TELBIL-A project”