Rijeka pilot

Target group:
Older people (+65) that had a myocardial infarction and finished rehabilitation.

Scope:
The personalized integrated value-based care will be set and coordinated by a multidisciplinary care team led by scientific team from the Department of Social Medicine and Epidemiology of Faculty of Medicine, University of Rijeka in collaboration with participant´s GPs, community nurses from Community Health Centre Primorje-Gorski Kotar County, 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.

To enhance the intervention phase, the Public Health Lab at the Department of Social Medicine and Epidemiology of Faculty of Medicine, University of Rijeka was established. The participants will come every three months during the intervention phase and do additional analysis of health parameters such as height, weight, visceral fat [%], total body fat [%], skeletal muscle [%], BMI, resting metabolism [kcal], blood pressure [mmHg], heart rate [b/min], oxygen saturation [%], subcutaneous fat [mm], left- and right-hand dynamometry [kg], ECG, spirometry and blood glucose level [mmol/L]. These analyses will broaden the personalised care approach and give opportunity to health care professionals to better adapt the needed care pathway for each participant.

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.