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Phone assessment in view of telemedicine approach for NCD patients


Blerta Haxha- Mahmutaj ,

Accessible Quality Healthcare Project, Stph, Kosovo
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Genc Ymerhalili,

Merita Shehu,

Manfred Zahorka,

Jana Gerold



The Accessible Quality Health (AQH) project in Kosovo is a Swiss Development Cooperation (SDC) funded project implemented by the Swiss Tropical and Public Health Institute (Swiss TPH) with a focus on NCD management in Primary Health Care (PHC). The quality of PHC services in Kosovo is weak due to the lack of infrastructure and multi-sectoral cooperation. AQH has piloting a telemedicine approach via telephone assessment and follow-up of NCD patients in a pilot project municipality.

Description of practice change implemented

Patients diagnosed with diabetes and hypertension have the possibility to get advice and answers to the questions through telephone consultations with their nurses. Nurses in Health Resource Centres from one Integrated Care pilot project municipality, who were previously trained on Motivational Counselling, contacted patients in their homes through phone calls. Based on findings from phone assessment they decided whether is needed further support or only gave them advises through phone.


The aim of IC Initiative is to improve the wellbeing and functional status of patients through better coordination of services provided by the health and social sectors. The objective of the telephone assessment for patients to increase capacity for self-management and to stay healthy.

Targeted population and stakeholders

Patients over the age of 65yrs with Type 2 Diabetes and Arterial Hypertension.


Started in May 2020 after the pandemic crisis with COVID-19 and will continue throughout the duration of the project until the end of 2023.

Highlights - Results

IC as a new concept in Kosovo promotes person-centred care and boosts the motivation for patients to stay healthy. During the pandemic it also avoids additional risks of virus infection through close contact with other patients. At this early stage, we only have output results while the outcome results can be expected at later stages. From May to December 2020, 175 patients over the age of 65 with type 2 diabetes were contacted, of which 115 females and 60 males. Every six months a data will be collected and changes and adaptions as per need.


The phone assessment is designed in collaboration with PHC management and the same were introduced to the nurses in MFMC.


AQH collaborates closely with the Ministry of Health and health teams from half of Kosovo municipalities. The results of this pilot project are shared with the Kosovo medical community.

Conclusions and Discussion

Telemedicine is a new feature in the Kosovo PHC sector. The IC concept has fostered developments towards a patient centred approach and an intensified contact to people living with NCDs. Direct phone contact and follow up is a simple technology, which can be used to reach otherwise difficult to reach patient groups.


Although current experience is limited due to the short duration of this pilot exercise, messages received from patients and from professionals are encouraging.

Lessons learned

Contacting patients remotely proved to be effective on motivating patients to socially interact and enhancement of confidence to safely stay healthy.




How to Cite: Haxha- Mahmutaj B, Ymerhalili G, Shehu M, Zahorka M, Gerold J. Phone assessment in view of telemedicine approach for NCD patients. International Journal of Integrated Care. 2022;22(S1):115. DOI:
Published on 08 Apr 2022.


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