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Personalised Connected Care for Complex Chronic Patients: Results from the CONNECARE Project


Eloisa Vargiu

Eurecat, Centre Tecnòlogic de Catalunya - eHealth Unit, ES
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CONNECARE “Personalised Connected Care for Complex Chronic Patients” is a H2020 Research and Innovation Project, started on April 2016 and that will finish on December 2019. CONNECARE is a technologically-oriented initiative aiming at exploring digital tools to support two key requirements of integrated-care services for chronic patients, namely: (i) Smart adaptive case management of patients with multimorbid conditions; and, (ii) Collaborative work among the various stakeholders, including patients and their families across health and social care tiers, involved in the services. The CONNECARE model consists of two major components: an organizational model for integrated-care and a technological platform to support the integrated-care organizational processes. The CONNECARE approach has been an implementation research approach, using an observational study design focused on implementing the CONNECARE organizational model and technology in real-life clinical setting with an intervention group and matched control group in four implementation sites: Barcelona, Lleida, Israel, and Groningen. The CONNECARE platform has been deployed in two situations: 1) Community-based prevention of unplanned hospital-related events in chronic complex patients with high risk for hospitalization (ImplementationStudy1), and 2) Preventive patient-centered intervention in complex chronic patients undergoing elective major surgical procedures (ImplementationStudies2&3). While the objectives and desired outcomes are the same in all sites, the organizational model for integrated-care and the supporting digital tools have been adapted to the specific needs of each site. ImplementationStudy1 focused on patients identified in a hospital setting – either in the emergency room or in the hospital who are then discharged back to their home in the community in a transitional care context or in a primary care context; or patients living at home but receiving (intensive) medical services due to the complexity of their condition. The target group of the ImplementationStudies2&3 is high-risk patients undergoing an elective major surgical procedure in all four sites. A total of 288 patients have been involved. Overall, patient satisfaction with both the services and the technology was very positive although there were some significant differences among the sites. While different measures were used to assess the services itself as opposed to the technology, it is fairly clear, particularly from patient comments and their relatives, that the two were very intertwined. As CONNECARE is an integrated care project, the assessment of the service focused on how patients perceived the service as being patient-centered if it met their needs and abilities and to what extent they perceived the care they received as “integrated”. The satisfaction with the technology as measured by Likert Scales/Net-Promoter-Score and the System-Usability-Scale was high, despite a significant number of challenges encountered along the way. Satisfaction was clearly linked to the perception that the digital tools were part of an overall integrated-care process and the relationship between professionals and patients. The most valuable results came from the evaluation at each site of the organizational processes involved in the implementation and the lessons learned will be crucial in scaling up the deployment of digitally-enabled integrated care in the four sites beyond the project’s end.

How to Cite: Vargiu E. Personalised Connected Care for Complex Chronic Patients: Results from the CONNECARE Project. International Journal of Integrated Care. 2021;21(S1):252. DOI:
Published on 01 Sep 2021.


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