Project ValueCare Pilots
Rijeka Pilot Site
Target group: older people (>65) with high blood pressure.
Scope: The personalized integrated value-based care will be set and coordinated by a multidisciplinary care team led by scientific team of Faculty of Medicine Rijeka in collaboration with participant´s GPs, community nurses from Community Health Centre Primorje-Gorski Kotar, health professionals/cardiologists from Thalassotherapia Opatija and Clinical Hospital Centre Rijeka. Informal caregivers, volunteers and NGOs will be also included to enhance the experience of older people through innovative digital solutions. Monitoring of participants progress after rehabilitation will be supported by the ValueCare digital solution which involves a corresponding mobile application for the participants, main dashboard/service platform and the individualized approach of volunteers.
The ValueCare digital solution/mobile application will measure the amount of physical activity of included participants, monitor the adherence to pharmacotherapy and provide a personalized nutrition plan adjusted to health condition of each participant. In case of emergency, the mobile application will also have a SOS button so the informal caregivers and health professionals can intervene in time. To measure physical activity, participant´s smartphone will be connected to a wearable IT device (smartwatch) that will monitor heart rate, oxygen saturation, number of steps, calories and sleeping patterns. All data will be stored in a defined cloud service and will be analysed, so the progress and any other changes can be processed.
With help of the main dashboard/service platform and in collaboration with GPs, community nurses and cardiologists, Rijeka pilot site team will regularly review and monitor the health status of the participants as well as send individualized alerts, reminders and automatic messages to the mobile application.
Besides that, special and personalized physical activities will be organized to improve the health condition of the participants.
Based on the collected data, health professionals will be able to detect the patterns of behaviour of each participant and their lifestyle (physical activity, healthy eating, sleeping patterns, etc.). This will help in developing a specific individualized approach in order to improve the quality of life of older people, their families and professionals working in health and social care.
Valencia Pilot Site
In the Valencia pilot, the solution aims to improve the quality of life of frail older adults by fostering healthier lifestyles and ageing. This solution will be based on a holistic approach encompassing both health and social care, and accordingly including an integral social and health pathway. Thus, the technical solution will create value for patients, their relatives, and it will also provide a customised health plan for each person supported by social and health professionals.
Valencia pilot is targeted to older adults with mild to moderate frailty, and their families, from one of the vulnerable districts covered by Health Department Valencia- Clínico-Malvarrosa Area.
How it works i.e. how it will use ICT / description:
Valencia ValueCare pilot will test the use of ICT technologies and devices (smartphones and tablets) to motivate adherence to the treatment and healthy lifestyles. In particular, a mobile app will suggest a tailored and individualised health plan prescribed to each participant by GPs. This plan will combine medical and social prescriptions as well as information from community and social services.
Through this free mobile app, patients can easily access useful health information, as well as health services and social activities in their communities. Older adults will be able to control their own health data and check different medical recommendations and prescriptions. For those people that could be affected by the digital divide, ValueCare also provides group sessions for training, motivation and upskilling.
Older adults can receive tailor-made information about physical exercise, cognitive stimulation and healthy habits with the full support of health and social care professionals. Besides, health practitioners can receive and check information on the activity of patients, and they can adapt the customised integrated health plan according to the evolution of participants, among other functionalities.
Cork/Kerry Pilot Site
In Ireland, the ValueCare project focuses on co-designing a digital solution to help older people (≥75) experiencing mild to moderate frailty to live independently in their homes. The technology will foster regular communication between older people in the relevant organisations (primary, secondary and social care) with technology enabled data sharing & common data sets can improve flow and information exchange. Older people will access the VALUECARE integrated care pathway via referral from primary care, the emergency department, the acute medical unit or the public health nurse. The care coordinator will develop the following 4 components; case finding; needs assessment; care planning and care co-ordination.
The research involves a two-phase approach; the first phase focuses on the co-design of a digital solution with key stakeholders (older people, formal and informal carers, health and social care providers), while the second phase involves the implementation of the co-designed digital solution at the designated Cork and Kerry pilot sites. Co-design is as specific value-driven approach which uses real-life experiences of people with health conditions and healthcare providers to improve service design and delivery. Stakeholders are involved as equal partners and co-creators, and the experiences of users and communities are at the core of the design process.
Coimbra Pilot Site
Target group: senior people in frail conditions, with no or mild cognitive impairment, and in need of social support (living at home and benefiting from CDC’s daycare, home support services or other – e.g., from residential units);
Stakeholders involved: it will involve health and social care professionals (GP, nurses, social workers, psychologists, social animators and educators), from public and private services (namely from the Primary Care services and from CDC) and also the users’ informal carers;
Scope: An individual care plan (ICP) will be set and coordinated by CDC’s clinicians, in collaboration with the user’s General Practitioner, also involving the care staff from CDC (psychosocial team), the primary care services and the older adult informal carers. The respective monitoring of its progress will be done through an IT supportive environment, involving a dedicated app, a service platform, and presential visits, whenever possible. The ValueCare digital solution will be available for both primary care and psychosocial support teams, allowing them to provide directions and guidelines related to the user’s ICP, as also to send alerts, reminders, and automatic messages to the app. In case of clinical emergencies, the medical team will be able to intervene and contact the older adult and his/her carer, asking them to reach out for medical services. The psychosocial support team will also have access to the digital solution, in order to regularly review and monitor the status of the older person, over the study, in terms of their risk of fall, patterns of social engagement, healthy eating, physical activity, sleep, etc. Based on the wealth of data collected, algorithms will be developed to detect patterns of behaviours that keep citizens healthy and active at home for longer, or under contrary, patterns of behaviours that can predict health deterioration, aggravating the existing frailty status.
Treviso Pilot Site
Target group: older citizens with mild cognitive impairments or with high levels of hypertension or T2 diabetes.
The Italian pilot will use an online coaching digital solution at twofold level: (i) one strand is related to formal caregivers, mainly nurses role, providing enhancing their self-care management skills; (ii) the other is to improve the awareness of citizens about how they are running their everyday habits in terms of nutrition, movements, and social relationships making them healthier and connected to the existing prevention and health services and consultancy.
Thanks to the use of wearable technologies IoT and the connection with a central health and behavioural data processing via AI digital solution, AI will deliver constantly feedbacks based on behavioural patterns gathered via IoT information coming from the environmental devices located into private homes such as oven, fridge, doors and other facilities plus the wearable devices chosen.
Based on the AI online, the VALUECARE concept will be addressed to three main health determinants: nutrition, physical activities practice and the quality of social relationships. In this pilot, the use of rewards will be also considered depending on individual behaviour (such as getting other services opportunities for free) and group results and its dynamics (based on the average age group outcomes such as weight loss, number of kilometres done). The group will be able to donate in amounts of tokens that could be changed into concrete and useful services for those who cannot get access to preventions or care services.
Athens Pilot Site
Target group: The Athens pilot is dealing with older adults over the age of 65 (and informal caregivers), withType 2 Diabetes Mellitus and Hypertension, living independently in the community.
Stakeholders involved: an online support and coordination of care multidisciplinary team consisting of medical, paramedical and psychosocial professionals from 2 organizations, AMC (medical, nurse) and AFIC (psychosocial support) as well as informal caregivers (family members, peers of patients). In the Athens pilot site the ICHOM set of Outcomes for Diabetes (Type I and II) and Clinical and Lifestyle Variables and Outcomes (Questionnaires) relevant to Type II Diabetes Mellitus will be collected from patients, their formal and informal caregivers.
This pilot will use both the VALUECARE app and the back-end digital solution. In addition, the target group and the informal carer (family member, peer) can receive online psychosocial support via a help-desk service operating via the online digital solution (teleconference sessions).
AI/ML algorithms will be developed to (1) detect patterns of behaviours that keep patients healthy and active at home for longer periods of time as well as (2) patterns of behaviours that can predict deterioration of frailty status and underlying disease and give prognostic information.
Rotterdam Pilot Site
The Rotterdam pilot will be focused on older adults who have suffered a stroke, their families, and health and social care providers. In 2018, a partnership was established between the local academic hospital (Erasmus Medical Centre), two rehabilitation clinics and a nursing home to encourage the delivery of integrated care for stroke patients in Rotterdam and the wider region. In ValueCare, this partnership will be extended with stakeholders in primary care (GPs, physiotherapists), social care (municipality), and informatics (IT experts). Together with patients who have suffered a stroke, their caregivers, and health and social care professionals, these stakeholders will be invited to share their experiential knowledge and expertise in a process of co-creation to develop the ValueCare intervention. Examples of core elements that might be adopted as part of the ValueCare intervention in Rotterdam are:
- ongoing assessment and follow-up of health and social care outcomes in all patients;
- a patient-centered integrated care plan to guide personalized care;
- a formalized process of interprofessional communication and collaboration;
- implementation of a personal health record to improve continuity of care;
- support of mobile health solutions to encourage healthy lifestyle.
Eligible patients will be asked for their consent to participate in the intervention soon after admission to the Erasmus Medical Centre. Each patient will be followed for 24 months. At several points in time, patient-reported outcomes and experiences are measured with an adapted version of the ValueCare questionnaire to the Rotterdam context.