Digital Health Europe

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

Keywords: (Clinical) Decision Support Services, Care Plans and Planning, Chronic Diseases, Integrated Care, Self-Management
Short description
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
Proof of concept is available: it works in a test setting and the potential end-users are positive about the concept 
Geographical scope
Submitted in other database or repository of digital health resources that is publicly available, DHE catalogue

Additional information

to clinicians / care practitioners
Clinical decision support
Care pathway tracking and adherence
Clinical team care planning and collaboration tools (e.g. digital shared care plan)
to patients / citizens
Telehealth and telemedicine
Primary target patient group (age)
May be used across all patient ages
Use case and care pathway positioning
Disease monitoring, treatment compliance, self-management, Integrated care pathways