This document summarizes information about the CONNECARE project, which aims to provide connected care for complex chronic patients in Lleida, Spain. The project focuses on improving communication between primary care and hospitals to better coordinate care for these patients. It develops a case management system using risk stratification and remote monitoring to prevent acute situations for complex chronic patients. The system includes self-management tools for patients. An initial study involved 28 complex chronic patients in Lleida to test the CONNECARE approach to integrated management across primary care and hospitals.

1. Connected Care for Complex
Chronic Patients in Lleida
Eloisa VARGIU, Juan Manuel FERNÀNDEZ, Felip MIRALLES
Mireia Massip, Gerard TORRES
Felix MICHEL, Florian MATTHES

2. Complex Chronic Patient
• It is a clinical assistive concept
• There is not a unified definition
• Complex Chronic Patient (CCP): A person with
a health and social care perceived quite difficult
by the team of professionals in charge
• Complex Chronic Patient (CCP): A patient with
one or more chronic condition, with comorbidities
or multimorbidities for causes
• Intrinsic: clinic o dependent on the treatment
adherence
• Extrinsic: social and/or dwelling environment
has several problems with high frequency and
needs several resources
2

3. Complex Chronic Patient
• 5% of the population
• 40% of the health budget is devoted to give
support to this kind of patients
• 40% of the patients are in acute hospitalization
3

4. Complex Chronic Patient

5. Clinic or socio-familiar event
When is the right moment to act?

6. Clinic or socio-familiar event
Frail patient that does not start to consume resources, yet
When is the right moment to act?
1
1

7. Clinic or socio-familiar event
Frail patient that does not start to consume resources, yet
At primary care: patient that has been already hospitalized at least once and go to
primary care for a control
When is the right moment to act?
1
1
2
2

8. Clinic or socio-familiar event
Frail patient that does not start to consume resources, yet
At primary care: patient that has been already hospitalized at least once and go to
primary care for a control
At the hospital: hospitalization of a patient that has already been hospitalized 1 or more
times
When is the right moment to act?
1
1
2
2
3
3

9. What CONNECARE is aimed to

10. • Risk stratification
 Clinic validation
o Comorbidity
o Cognitive and emotional
o Functional
 Barrier identification
o Therapeutic adherence
o Self-care ability
o Physic environment
o Social environment
Underlying needs
• A work plan agreed among primary care doctors and
hospital staff (need of communication)
• Preventive actions at ambulatory level

11. 11
1. Improvement of communication and information flow between primary
care and hospital to work together
2. Remote monitoring of clinic variables and improvement of
communication among the professional team and the patient to prevent
acute situations
“All to one and better to anticipate problems”
The CONNECARE solution

12. Hospital
Information
System
Primary care
Information
System
The CONNECARE solution

13. Case Identification
Case Evaluation
Work plan defined together and
agreed by the parts
Discharge
The CONNECARE process

14. 14
The CONNECARE vision

15. Smart Adaptive Case Management
15

16. Smart Adaptive Case Management
16

17. Smart Adaptive Case Management
17

18. Smart Adaptive Case Management
18

19. Self-Management System
19
Health Status
Physical Activity
Simple Tasks
Questionnaires
Drugs Prescription

20. Self-Management System
Profile / Settings
Notifications
Messages
Advices
Educational Material
System Notifications
Devices
configuration

21. CONNECARE in Lleida
21
Population: ≈ 400k people
Hospitals:
Hospital Universitari Arnau de Vilanova (HUAV)
Hospital Universitari de Santa Maria (HUSM)
≈ 500k office visits/year
≈ 14k admissions/year
Primary Care:
23 Primary Care centres (12 of them 24h)
1 Primary Care emergency centre

22. CONNECARE in Lleida
22
 28 patients;
 50% women;
 Median (min-max) age 84 (55-95)
 Median (min-max) Charlson 7 (2-10);
 Median (min-max) LACE 14 (9-19)
Studies started on July 2018 in Lleida region focuses
on integrated management of:
 CS1 - CCP with medical worsening
 CS2 - CCP undergoing surgical procedures
Current situation:
 1 case manager from the Hospital Santa Maria
 31 hospital professionals
 50 primary care professionals
CS1
 29 patients;
 59% women;
 Median (min-max) age 75 (56-86)
 Median (min-max) Charlson 4 (1-9)
CS2

23. CONNECARE @ICIC19
23
Poster 220
Poster 219
Poster 302
Overcoming Integration
Failure Through Negotiation
– A Workshop for Doers and
Planners CONNECARE: A
Bridge Over Troubled Waters
Workshop
Tuesday, April 2nd
14:00 – 15:30
5F

24. Thanks
Gràcies
This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 689802
Bedankt ‫תודה‬
Grazie Danke
eloisa.vargiu@eurecat.org