Periodic Reporting for period 2 - CAREPATH (An Integrated Solution for Sustainable Care for Multimorbid Elderly Patients with Dementia)
Reporting period: 2023-01-01 to 2024-06-30
CAREPATH will provide a holistic environment that efficiently addresses multimorbidity and dementia challenges in elderly population by delivering three complementary components:
- Home and Health Monitoring platform integrated with Advanced Early Warning Smart Decision Tools, providing environment aware services with natural and comfortable interfaces for older adults for continuously collecting real time data for early detection of onset and changes in functioning, autonomy, underlying cognitive and physiological functions and to derive dementia profiles and intrinsic capacity of these patients.
- Patient Empowerment Platform, providing personalized assistance to the patients, guidance and reminders about care plan goals and activities, present educational materials for reinforcing treatment adherence; collect feedback from the patients via Patient Reported Outcome Measures (PROMs) for carrying out geriatric assessments.
- Adaptive Integrated Care Platform, enabling implementation of adaptive care plans for managing multimorbidity based on evidence based clinical guidelines but prioritizing and reconciling them with the help of clinical decision support systems processing patient’s most recent context from the home monitoring environment (derived dementia profile and intrinsic capacity, behavioral change patterns) and also from Electronic Health Records (EHRs) for calculating risk scores for comorbidities and monitor disease progression and intervention effects and tackling polypharmacy management.
The project specific objectives can be described as:
- Specific Objective 1 (SO1): Develop a holistic, open-standards based, inclusive, cross-sectoral and interdisciplinary patient-centred approach to improve the Quality of Life (QoL) of elderly patients, whose multimorbidity includes dementia.
- Specific Objective 2 (SO2): Implement the CAREPATH patient-centred approach through an integrated ICT platform that jointly and efficiently addresses multimorbidity and dementia challenges while also considering the intrinsic capacity of the patient, leading to a high degree of self-management of patients and significant support for the informal and formal caregivers. As a new care pathway and healthcare model for the management of multimorbid elderly patients, this approach brings together a health and home monitoring platform, with intelligent data analytics tools to estimate dementia profiles and intrinsic capacity of patients; an integrated care management environment for multidisciplinary care teams, with intelligent decision support services (based on computer interpretable guidelines), to adapt the Care Plan of the patient based on his most recent health and wellbeing parameters and multimorbities as well as dementia profile and intrinsic capacity; a framework for polypharmacy management; and a patient empowerment platform.
- Specific Objective 3 (SO3): Perform Technical Validation and Usability (TVU) study to evaluate usability, users’ experience and safety of the CAREPATH ICT platform by collecting feedback from stakeholders in four pilot sites across Europe including in total 16 patients with their informal caregivers and 16 healthcare professionals as they are part of the multidisciplinary care model for multimorbid patients with MCI or dementia at pilot sites, in order to enhance the platform capabilities, predict future adoption and diffusion of the technology and match it to the market expectations.
- Specific Objective 4 (SO4): Conduct representative two-year Clinical Investigation (CI) campaign, to provide initial and indicative clinical validation of the implemented platform, in different European sites (four countries), with at least 52 patients, i.e. patients that suffer simultaneously from multimorbidity and dementia (multimorbid patients with Mild Cognitive Impairment – MCI or mild dementia) per site (26 patients who will use the CAREPATH platform and 26 ones as reference cases). All patients will be involved for one year in the trials together with at least one informal caregiver and a healthcare professional.
- Specific Objective 5 (SO5): Propose a technology-driven framework enabling patient-focussed Integrated Care pathways, with associated healthcare models for the management of multimorbid elderly patients with dementia, in order to improve the Quality of Life (QoL) of such patients.
- Specific Objective 6 (SO6): Elaborate on a methodology for computer interpretable clinical guidelines and computationally derived best clinical practice for the improved management of elderly multimorbid patients with dementia.
- Specific Objective 7 (SO7): Develop Quality Key Performance Indicators (QKPIs) for the management of multimorbid elderly patient with dementia exploiting the findings of the CAREPATH two-year CI.
- Specific Objective 8 (SO8): Address and assess the relevant health economic impacts of the solution, in terms of cost effectiveness and care provision inequalities.
- Home and Health Monitoring platform integrated with Advanced Early Warning Smart Decision Tools, providing environment aware services with natural and comfortable interfaces for older adults for continuously collecting real time data for early detection of onset and changes in functioning, autonomy, underlying cognitive and physiological functions and to derive dementia profiles and intrinsic capacity of these patients.
- Patient Empowerment Platform, providing personalized assistance to the patients, guidance and reminders about care plan goals and activities, present educational materials for reinforcing treatment adherence; collect feedback from the patients via Patient Reported Outcome Measures (PROMs) for carrying out geriatric assessments.
- Adaptive Integrated Care Platform, enabling implementation of adaptive care plans for managing multimorbidity based on evidence based clinical guidelines but prioritizing and reconciling them with the help of clinical decision support systems processing patient’s most recent context from the home monitoring environment (derived dementia profile and intrinsic capacity, behavioral change patterns) and also from Electronic Health Records (EHRs) for calculating risk scores for comorbidities and monitor disease progression and intervention effects and tackling polypharmacy management.
The project specific objectives can be described as:
- Specific Objective 1 (SO1): Develop a holistic, open-standards based, inclusive, cross-sectoral and interdisciplinary patient-centred approach to improve the Quality of Life (QoL) of elderly patients, whose multimorbidity includes dementia.
- Specific Objective 2 (SO2): Implement the CAREPATH patient-centred approach through an integrated ICT platform that jointly and efficiently addresses multimorbidity and dementia challenges while also considering the intrinsic capacity of the patient, leading to a high degree of self-management of patients and significant support for the informal and formal caregivers. As a new care pathway and healthcare model for the management of multimorbid elderly patients, this approach brings together a health and home monitoring platform, with intelligent data analytics tools to estimate dementia profiles and intrinsic capacity of patients; an integrated care management environment for multidisciplinary care teams, with intelligent decision support services (based on computer interpretable guidelines), to adapt the Care Plan of the patient based on his most recent health and wellbeing parameters and multimorbities as well as dementia profile and intrinsic capacity; a framework for polypharmacy management; and a patient empowerment platform.
- Specific Objective 3 (SO3): Perform Technical Validation and Usability (TVU) study to evaluate usability, users’ experience and safety of the CAREPATH ICT platform by collecting feedback from stakeholders in four pilot sites across Europe including in total 16 patients with their informal caregivers and 16 healthcare professionals as they are part of the multidisciplinary care model for multimorbid patients with MCI or dementia at pilot sites, in order to enhance the platform capabilities, predict future adoption and diffusion of the technology and match it to the market expectations.
- Specific Objective 4 (SO4): Conduct representative two-year Clinical Investigation (CI) campaign, to provide initial and indicative clinical validation of the implemented platform, in different European sites (four countries), with at least 52 patients, i.e. patients that suffer simultaneously from multimorbidity and dementia (multimorbid patients with Mild Cognitive Impairment – MCI or mild dementia) per site (26 patients who will use the CAREPATH platform and 26 ones as reference cases). All patients will be involved for one year in the trials together with at least one informal caregiver and a healthcare professional.
- Specific Objective 5 (SO5): Propose a technology-driven framework enabling patient-focussed Integrated Care pathways, with associated healthcare models for the management of multimorbid elderly patients with dementia, in order to improve the Quality of Life (QoL) of such patients.
- Specific Objective 6 (SO6): Elaborate on a methodology for computer interpretable clinical guidelines and computationally derived best clinical practice for the improved management of elderly multimorbid patients with dementia.
- Specific Objective 7 (SO7): Develop Quality Key Performance Indicators (QKPIs) for the management of multimorbid elderly patient with dementia exploiting the findings of the CAREPATH two-year CI.
- Specific Objective 8 (SO8): Address and assess the relevant health economic impacts of the solution, in terms of cost effectiveness and care provision inequalities.
The work performed in the project during the first reporting period can be seen at different plans:
- the user requirements and key scenarios definition,
- the Integrated Care Platform architecture design,
- the implementation of several components of the Integrated Care Platform: H/HMP, PEP, AICP, AEWDT...
- implementation of the security and privacy suite and the interoperability framework,
- holistic clinical guideline for the CAREPATH project, and their computer interoperable implementation.
- the user requirements and key scenarios definition,
- the Integrated Care Platform architecture design,
- the implementation of several components of the Integrated Care Platform: H/HMP, PEP, AICP, AEWDT...
- implementation of the security and privacy suite and the interoperability framework,
- holistic clinical guideline for the CAREPATH project, and their computer interoperable implementation.
CAREPATH will have major impacts, specifically at the level of socio-economic and societal implications:
- CAREPATH Integrated Care approach and supporting ICT components will improve delivery of integrated care services to elderly patients with multimorbid conditions. CAREPATH Integrated Care Platform and supporting Clinical Decision Support (CDS) services will enable multidisciplinary team of health and social care givers to collaboratively create, execute and monitor personalised care plans through reconciliation of clinical guidelines. Clinical Decision Support Modules will also enable risk stratification, poly-pharmacy management and goal setting and monitoring.
- CAREPATH evaluation activities will take advantage of the data collected during pilot operation in diverse settings to analyze the trajectories of elderly patients whose care is being managed through personalised care plans created by reconciliation of clinical guidelines. The main goal will be to manage cross-referencing in multimorbidity management, i.e. identify care guideline steps for one disease that adversely impact another disease and its management, which can include drug-drug interactions, drug-condition interactions, complicated side-effects, or simply clashes in guideline advice. These care plan issues, which are identified and logged in the CAREPATH platform, will then be reviewed by a clinical reference group comprising relevant experts selected from the pilot sites, in order to assess the strength of the evidence as a basis for recommending changes to the established clinical guidelines.
-Achieving Integrated Care Quality Key Performance Indicators (QKPIs) for a multimorbid patient’s health status is one of the key elements in supporting initiatives to self-care. Therefore, CAREPATH will be contributing to achieving this through and inetgated care platform and will measure these during pilot validation studies.
- CAREPATH Integrated Care approach and supporting ICT components will improve delivery of integrated care services to elderly patients with multimorbid conditions. CAREPATH Integrated Care Platform and supporting Clinical Decision Support (CDS) services will enable multidisciplinary team of health and social care givers to collaboratively create, execute and monitor personalised care plans through reconciliation of clinical guidelines. Clinical Decision Support Modules will also enable risk stratification, poly-pharmacy management and goal setting and monitoring.
- CAREPATH evaluation activities will take advantage of the data collected during pilot operation in diverse settings to analyze the trajectories of elderly patients whose care is being managed through personalised care plans created by reconciliation of clinical guidelines. The main goal will be to manage cross-referencing in multimorbidity management, i.e. identify care guideline steps for one disease that adversely impact another disease and its management, which can include drug-drug interactions, drug-condition interactions, complicated side-effects, or simply clashes in guideline advice. These care plan issues, which are identified and logged in the CAREPATH platform, will then be reviewed by a clinical reference group comprising relevant experts selected from the pilot sites, in order to assess the strength of the evidence as a basis for recommending changes to the established clinical guidelines.
-Achieving Integrated Care Quality Key Performance Indicators (QKPIs) for a multimorbid patient’s health status is one of the key elements in supporting initiatives to self-care. Therefore, CAREPATH will be contributing to achieving this through and inetgated care platform and will measure these during pilot validation studies.