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Personalised Connected Care for Complex Chronic Patients

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Digital tools to support integrated-care services for patients with chronic conditions

Patients with complex chronic conditions suffer from multiple morbidities and often require continuous care at home. A European initiative developed a smart self-management system for these patients, aiming to improve care provision.


Across Europe, seven out of ten hospital beds are occupied by people with chronic conditions, necessitating integrated long-term care. Reducing associated costs and improving care requires careful coordination of the healthcare and social welfare systems.

Digital tools for integrated care

To address this issue, the EU-funded CONNECARE project explored digital tools to support adaptive case management of chronic patients and collaborative work among the various stakeholders, including patients and their families. A self-management system in the form of an app installed on patients’ smartphones or tablets monitors various patient parameters including physical activity and health status through medical devices and self-reported questionnaires, rehabilitation tasks, sleeping activity and drug intake. Apart from accessing their data and monitoring their health, patients can communicate with clinicians for feedback. In case of anomalies, and to prevent and avoid dangerous and uncontrolled situations, healthcare professionals are sent alerts on the smart, adaptive case-management system, accessible via the web. This offers them the opportunity to promptly change patient medication and prevent rehospitalisation. At the same time, if patient health improves, clinicians can reorganise their healthcare plan. Advice and recommendations are also available through text, images, or videos. “To improve patient engagement and satisfaction, the app must be perceived as an integral part of treatment,” emphasises project coordinator Felip Miralles. For this purpose, considerable effort went into a simple app design with few yet clear and effective functionalities. Patients exhibited greater engagement, knowing that they were being monitored and receiving input from healthcare professionals.

CONNECARE impact and future prospects

The CONNECARE system was tested under real clinical practice rather than pilots or controlled studies. For this purpose, the basic CONNECARE system was adapted to four clinical situations in three locations in the Netherlands, Spain and Israel,. These sites represented different healthcare models, with variations in patient management protocols and IT infrastructures. The aim is to transfer the technology to other regions in Europe in the future. Implementation of the app demonstrated an immediate impact on the patients and institutions involved. “For citizens with chronic conditions, CONNECARE offers a new model of healthcare with immediate benefits,” continues Miralles. With these novel digital tools, the CONNECARE project provides a comprehensive approach to the challenge of vertical and horizontal integration of health and social care for enhanced management of multi-morbidity. Benefits can be seen on both social and organisational levels. Doctor appointments are coordinated and services from different hospital departments are delivered sequentially or simultaneously without disruptions, enhancing efficiency and outcome of care. Interestingly, patients engage in new social and physical activities – with important consequences for their health. Overall, CONNECARE addresses the need for new digital health infrastructure with respect to patient records and workflow management systems. Importantly, it has the power to provide evidence on the effectiveness of clinical interventions, self-management resources or behavioural coaching interventions, at a global scale. The CONNECARE system is ready to support patients with any pathology. During the current COVID-19 pandemic, CONNECARE could serve as a means of remote monitoring for infected patients at home or those who have been discharged from the hospital. The system can help address health issues remotely, offering the best healthcare advice possible.


CONNECARE, app, self-management system, complex chronic conditions, digital tool, smartphones, remote monitoring

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