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Personalised Connected Care for Complex Chronic Patients

Periodic Reporting for period 3 - CONNECARE (Personalised Connected Care for Complex Chronic Patients)

Reporting period: 2018-12-01 to 2019-12-31

CONNECARE aims to design, develop and evaluate a new organizational model to enable integrated care for complex chronic patients (CCPs), supported by technological solutions following an adaptive case management approach. The integrated care organizational model will facilitate collaboration among healthcare professionals, patients and their carers through integrated technological solutions. CONNECARE will also support and empower patients for self-management, by providing them recommendations according to continuous monitoring of their activities.
The CONNECARE solution needs to be scalable and thus requires sufficient flexibility while fulfilling all technical requirements, therefore is being designed in order to systematize the processes that will allow the fine-tuning of the CONNECARE integrated care solution, as well as its evaluation throughout the project.
Main achievements in the first reporting period are the following:
• 1st PDSA cycle completed
• 2nd PDSA started
• ACM specification for healthcare: A comprehensive study of the organisational and technological dimensions of ACM in healthcare has been taken into account in the co-design of the functional requirements of the SACM. Moreover, also existing site-specific organisational and technological settings within which CONNECARE case studies and technologies will be implemented have been investigated.
• Patient risk assessment study: The CONNECARE strategies to optimize patient-based health risk assessment and service selection in order to facilitate elaboration of individual care plans in the clinical scenario have been investigated.
• Detailed definition of case studies in each site: In each site, the case studies have been defined by professionals belonging to the involved hospitals and medical centres. Starting from their definition, each intervention has been then translated in the Case Management Model and Notation (CMMN) format useful to be then implemented in the SACM.
• Study of commonalities and differences in each site and for each case study: Due to the heterogeneity of the sites as well as of the defined case studies, a deep study in order to identify commonalities and differences has been performed as part of the 2nd PDSA cycle.
• First evaluation plan of the entire project: The steps and tasks required for the entire project evaluation have been defined. In particular, have been analysed the criteria used for identification of the different modalities of indicators, the methodological approach including clinical study designs, as well as the three main phases: (i) Initial co-design process; (ii) Clinical studies; and, (iii) Refinement & fine tuning process, defining and overall strategy for CONNECARE assessment.
• Requirements gathering of the CONNECARE system: One of the goals of PDSA cycles, in particular of the first one, was to define all the requirements for the two main subsystem to be develop in WP3 (SACM) and in WP4 (SMS). Functional and non-functional requirements have been gathered and selected according to a priority list that takes into account the requests from the different sites and the case studies.
• Customization of SocioCortex for healthcare: SocioCortex is incorporating extended functionalities for case modelling and execution, specifically tailored to the healthcare domain. Additionally, SocioCortex is implementing advanced access control methods, a higher-order functional language to compute derived attributes on the fly and more sophisticated search and indexing features.
• Professional Interface designed and online: The requirements and case studies developed during the co-design process were used in this task to create wireframe designs for the web-based Professional Interface. At each stage these designs were reviewed across the technical and clinical members of the team. This design was translated into a web app coded in Angular. Regular releases were made to allow the wider team clinicians to further steer the implementation.
• First CDSS for risk assessment and stratification: The 1st prototype of the CDSS is almost ready to be fully integrated in the SACM.
• Backend of the SMS defined and developed: The SMS back-end is based on the concept of microservices. The SMS includes the services defined and deployed to perform basic monitoring and some assistive monitoring. Thanks to its modularity, it is also ready to embed more services as well as external apps and applications.
• Basic monitoring services available
• Assistive monitoring services available
• Recommender system for physical activities: A first prototype of recommender system for physical activity monitoring has been implemented. Based on argumentation, it implements different strategies to support patients in their activities, sending also a feedback to professionals, if needed.
The ambition of CONNECARE is to become a reference project in the integrated care domain to health and care systems providers in Europe. Because CONNECARE is designing, implementing, deploying and evaluating methods and technologies in real clinical practice instead of pilots or controlled studies, our added value is firstly, to improve the real life deployment of integrated care in our 4 sites and eventually, to bring practical insight to the potential of transferability of new methods and technologies to all other regions in Europe and beyond, with the prospect of interesting business opportunities. The underlying objective of CONNECARE is to ensure the triple win: improved Quality of Life, improved sustainability of care systems and improved innovation based competitiveness of the EU industry.
Consequently, from that integrated care business line the expected impact is manifold:
• Social impact: Mix of services delivered sequentially or simultaneously by multiple providers. The patient will receive cure and care at home, and in institutional settings.
• Environmental impact: New solutions for elderly patient mobility and access to services and social activities.
• Organisational impact: Connectivity, alignment and collaboration within and between the cure and care sectors to enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients across multiple services, providers and settings.
In terms of exploitation and business plans, the project is still in the early stage and therefore has not attained mature and detailed plans. CONNECARE ultimate goal is to implement best quality integrated care methods and technologies in the 4 original regions of the project partners, but also eventually in the whole European Union, with the ambition that Europe would lead and become the standard for Integrated Health Care systems for the world.
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