Table 2.

Epital Care Model (ECM) actors.

Actor type	Short description
Person	An ECM-connected person is an individual with one or more chronic conditions who is a member of an ECM network. The person gradually moves to be a patient when the context shifts from ECM1 (active and independent living) towards ECM6 (hospitalized living).
Response and Coordination Center nurse	The Response and Coordination Center (RCC) nurse is the coordinator of the ECM network. The RCC nurse conducts population monitoring, initiates proactive contacts to ECM connected persons at risk, and coordinates the services in treatment for acute deteriorations. The RCC nurse is always backed up by a responsible eDoctor regarding prescriptions and decision making.
Mobile Acute Team nurse	Mobile Acute Team nurses are trained and certified in handling frail people, in collaboration with the eDoctors; this includes clinical assessment and investigations.
Subacute Surveillance Place nurse	Subacute Surveillance Place nurses are municipality nurses who are qualified to take care of the patients in the subunit.
eDoctor	The eDoctor is a medical doctor combining a medical specialty (typically general practitioner or internal medicine) with a specialization in eHealth. The eDoctor is capable of taking treatment responsibility in the ECM network, which includes virtual treatments according to the context filters in the ECM funnel.