CONNECARE: a novel smart, adaptive integrated care system for chronic care management

The ambition of the CONNECARE consortium was to co-design, develop, deploy, and evaluate a novel smart, adaptive integrated care system for chronic care management. Based on the concept of 4P medicine, CONNECARE aimed to provide decision support for the adaptive management of personalised clinical pathways and deliver tools to monitor patients’ activities and status, thus empowering them and providing them with recommendations to self-manage their condition, resulting in substantial improvements in their quality of life. The technological dimension included delivering a CONNECARE system which leveraged existing assets from partners to offer smart Adaptive Case Management, self-management and 3-level monitoring features, fully integrated with management systems in place. It has 2 major ICT components: 1) Smart Adaptive Case Management (SACM) for professionals: • Adaptive planning of clinical processes tailored to each patient • Collaborative management of all involved actors in each step • Management of patient’s information to better handle her/his case • Decision support to clinicians in each step of the process 2) Self-Management System (SMS) for patients • Patient’s monitoring (e.g., health status, activities, next tasks) • Interaction and communication between patient and professionals • Smart support to training, recommendations and alerts