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Integrated Care for Complex Chronic Patients

Authors:

Eloisa Vargiu ,

Eurecat Technology Center, eHealth Unit, ES
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Juan Manuel Fernàndez,

Eurecat Technology Center, eHealth Unit, ES
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Felip Miralles,

Eurecat Technology Center, eHealth Unit, ES
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Isaac Cano,

Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona, Barcelona, ES
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Elena Gimeno-Santos,

Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona, Barcelona; Center for Biomedical Network Research in Respiratory Diseases (CIBERES), ES
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Carme Hernandez,

Hospital Clinic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona, Barcelona; Center for Biomedical Network Research in Respiratory Diseases (CIBERES), ES
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Gerard Torres,

Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, Lleida, ES
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Jordi Colomina,

Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari de Santa Maria, IRBLleida, Lleida, ES
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Jordi de Batlle,

Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova and Santa Maria, IRBLleida, Lleida, ES
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Rachelle Kaye,

Assuta Medical Centers, IL
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Bella Azaria,

Assuta Medical Centers, IL
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Shauli Nakar,

eWAVE Medical, IL
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M.H. Lahr,

Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, Groningen, NL
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Esther Metting,

Department of General Practice, University Medical Center Groningen, Groningen, NL
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Margot Jager,

Department of Health Sciences, University Medical Center Groningen, Groningen, NL
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Hille Meetsma,

VitalinQ Lifestyle Support, NL
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Stefano Mariani,

Department of Sciences and Methods for Engineering, University of Modena and Reggio Emilia, IT
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Marco Mamei,

Department of Sciences and Methods for Engineering, University of Modena and Reggio Emilia, IT
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Franco Zambonelli,

Department of Sciences and Methods for Engineering, University of Modena and Reggio Emilia, IT
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Felix Michel,

Technische Universität München, DE
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Florian Matthes,

Technische Universität München, DE
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Jo Goulden,

Advanced Digital Institute, GB
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John Eaglesham,

Advanced Digital Institute, GB
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Charles Lowe

Advanced Digital Institute; Digital Health and Care Alliance, GB
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Abstract

Background: In 2006, 35% - 40% of the population in the EU aged > 65 years reported a longstanding health problem and one in four currently receives medical long-term treatment. In Catalonia, data from the 2011-2015 health plan reported that about 30% of the general population has at least one chronic disorder. It is widely accepted that this increasingly important group of the population may suffer frequent unexpected hospital admissions or emergency room visits because of clinical or social circumstances triggering adverse outcomes. Accordingly, the Complex Chronic Patient (CCP) is defined as a patient with at least one+ chronic diseases, comorbidities, frail (due to social, economic and/or clinical factors), usually elderly, and who consumes a very high level of health resources. Although CCPs comprise about 5% of the general population, their health care needs consume an estimated 40% plus of all hospital admissions.

Methods: CONNECARE (H2020-PHC-2015-689802) aims to develop and evaluate a new organizational model to enable integrated care of CCPs, supported by technological solutions following an adaptive case management approach. From the CCP’s perspective, different healthcare professionals are central to patients’ care: the general practitioners, specialist doctors, other hospital staff, and social workers. Moreover, the carers, unpaid relatives or friends, who typically deliver the majority of care that CCPs require, are indispensable. The CONNECARE integrated care organizational model will facilitate collaboration and communication among healthcare professionals, patients and their carers through integrated technological solutions in which the patients play a central role. CONNECARE will also support and empower patients for self-management, by providing them recommendations and suggestions according to continuous monitoring of their activities. CONNECARE will be deployed in three regions: Catalonia (Spain), Israel, and Groningen (the Netherlands).

Results: The CONNECARE integrated care solution is built upon the experience of on-going large-scale deployment programs in each of the participating sites and the inclusion of the main stakeholders in the process (healthcare professionals, patients, carers, insurance companies, and policy makers). Therefore, a co-design methodology has been established to capture the feed-back of all actors in the integrated care process.

Three clinical studies have been defined for field-testing the CONNECARE solution that will then be performed and evaluated (October 2016 to March 2019) in the three regions: community-based management of CCP, and integrated management of patients undergoing surgical procedures with a specific use case for pre-habilitation of high risk candidates for complex abdominal surgical procedures –which will only be performed and evaluated in Barcelona.

The purposes of the clinical studies are: (i) assessing health value generation of the CONNECARE solution; (ii) enabling its refinement and fine tuning during the last six-month period; and (iii) generating guidelines for transferability of CONNECARE achievements to other sites.

Conclusions: The ambition of CONNECARE is to co-design, develop, deploy, and evaluate a novel integrated care services model supported by a smart and adaptive case management system for better care coordination and self-management of CCPs. Pragmatic clinical trials will be held in the three sites to assess the health value generation of the CONNECARE solution. Guidelines for the transferability of CONNECARE achievements to other sites will be developed. This will save European healthcare organizations huge sums whilst improving patient outcomes.
How to Cite: Vargiu E, Fernàndez JM, Miralles F, Cano I, Gimeno-Santos E, Hernandez C, et al.. Integrated Care for Complex Chronic Patients. International Journal of Integrated Care. 2017;17(5):A302. DOI: http://doi.org/10.5334/ijic.3619
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Published on 17 Oct 2017.

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