This document describes the CONNECARE project, which aims to develop a personalized connected care system for complex chronic patients. The system seeks to optimize healthcare resources, engage patients, and provide collaborative support to healthcare professionals. It will take a predictive, personalized, preventative, and participatory approach. The CONNECARE consortium is co-designing a novel smart and adaptive integrated care system with professionals and patients, which will be implemented and evaluated in three clinical case studies across different regions. The project aims to reduce costs and improve outcomes for patients with multiple chronic conditions through more integrated long-term care.

1. Personalized Connected Care for
Complex Chronic Patients
Eloisa Vargiu – Eurecat Technology Center

2. CONNECARE at a Glance

3. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
CONNECARE Video
https://youtu.be/776CnQ0p0RI

4. Aim & Objectives

5. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
Aim & Objectives
The Challenge
More sustainable and optimized use of
healthcare resources
Engaging patients with a 360º approach
Self-management for patient
empowering
Collaborative and adaptive support to
professional staff
Support for decision making

6. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
Aim & Objectives
The chronic complex patient
Frail (due to social, economic and/or
clinical factors)
Usually elderly
With multi-morbidities
Who requires provision of care by several
health professionals pertaining to
different medical disciplines and working
in different healthcare tiers

7. A 3D Paradigmatic Shift

8. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
A 3D Paradigm Shift
Organizational Shift
Making health and social care systems
interoperable
Promoting collaboration among care
settings
Moving from institutional reactive care to
a home-based preventive model

9. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
A 3D Paradigm Shift
Care and Social Services Shift
Health risk prediction
 operational population-based tools
 a patient-based five-dimension
scoring strategy
Case Identification
Case Evaluation
Personalized Work-Plan
Definition
Work-Plan Execution
Follow-Up & Event Handling
Discharge

10. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
A 3D Paradigm Shift
Technological Shift
A CONNECARE system which leverages
existing assets from partners, fully
integrated with management systems in
place
 Smart Adaptive Case Management
 Self-management
 3-level monitoring features

11. The Approach

12. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
The Approach
The Basic Concept
CONNECARE is based on the concept of
4P medicine
 Predictive
 Personalized
 Preventive
 Participatory
CONNECARE will provide
 Decision support for the adaptive
management of personalized clinical
pathways
 Tools to monitor patients’ activities and
status
 Recommendations to self-manage patients’
condition

13. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
The Approach
Iterative Co-Design

14. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
The Approach
Clinical Studies
Three case studies
 Community-based prevention of
unplanned hospital-related events in
chronic complex patients with high risk
for hospitalization
 Preventive patient-centered
intervention in complex chronic patients
undergoing elective major surgical
procedures
 Pre-habilitation intervention in high risk
candidates for major surgery
Israel
Catalonia
Groningen

15. First Achievements

16. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
04/16
Cook Book
10/16
04/17
10/17
We’re
here!
Mock-ups
Case Studies
defined
1st prototype
System Architecture
Working teams
Evaluation forms

17. Conclusion

18. 2E Journée Innovation en Santé Publique – November 7th, 2017 – Lille (France)
Conclusions
Some 70% of hospital beds in Europe are
occupied by people with chronic long term
conditions
The project aims to reduce costs and improve
patient outcomes by improving the integration
of long term care for those chronically sick with
more than one long term condition
The CONNECARE consortium is co-designing
with professionals and patients, developing,
implementing, and evaluating a novel smart-
adaptive integrated care system

19. 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