CONNECARE implements a new organizational model for Integrated Care, enabled by ICT tools to support adaptive case management and empowerment of complex chronic patients. All professionals, both from primary care and hospital, as well as social workers, interact with each other using a collaborative tool to coordinate care plans and their execution, assuring continuity of care among hospital, primary care, and social care. Patients check their status and execute assigned tasks through a self-management system installed on their smartphones or tablets. Professionals may also accompany the patients using the messaging function of the case management tool and the patient's mobile application.
The CONNECARE model is based on a care process composed of 5 main stages: (i) Case Identification, to select patients eligible for entering the program; (ii) Case Evaluation, to comprehensively evaluate and stratify patients based on multilevel predictive modelling (clinical, environmental, and social); (iii) Workplan definition, to plan proactive and preventive interventions tailored to the personal condition and needs of the patient; (iv) Workplan execution, to continuously monitor patient adherence and the evolution of the personalized action plan, and (v) Discharge of the patient from the program with an evaluations of the results of the overall intervention. Patients may: monitor their physical activity, by relying on off-the-shelf activity trackers; answer questionnaires to assess anxiety and depression, quality of life, measure perceived pain, and evaluate self-care; monitor their health-status; monitor daily life activities performed at home; monitor medication adherence; and, communicate securely with healthcare professionals through messaging. Intelligence is delivered to patients and professionals in the form of automated, contextual, and personalized data analysis, predictive modelling and decision making, by dedicated ICT tools: a Recommender System (RS) and three Clinical Decision Support Systems (CDSS). The RS has two goals: encouraging patients’ compliance to prescriptions, and maintaining engagement of patients during treatment. The goal of the CDSSs is threefold: provide risk assessment and stratification services to healthcare professionals; provide geolocation services to identify patients on a map depending to severity of condition and socio-cognitive and economic barriers to treatment; and assist clinicians in designing personalized clinical pathways.
Implementation studies began in July 2018 in Catalonia, Groningen, and Israel and, to date, a total of 200 patients have been involved.
CONNECARE results have stimulated new initiatives aimed at applying Integrated Care at large-scale and considering specific case studies (e.g.., pre-rehabilitation to prepare patients for elective surgery and support to patients after an ophthalmic surgery).