Search

Introduction Persons with Advanced Chronic Diseases can greatly benefit from digitally supported interventions to improve or maintain their health, avoid unnecessary deterioration, extend their independence and optimize health resources utilization. Digitalisation is expected to lead a profound transformation of health services. It is important to evaluate its impact. The coronavirus disease (COVID-19) pandemic has pushed forward the paradigm shift towards telehealth, highlighting the need worldwide for enabling and promoting digital care. Theory/Methods The project ADLIFE (H2020, SC1-DTH-11-2019, 875209) aims to provide innovative integrated intelligent personalized care to aged patients with complex chronic diseases. Care will be supported by an ICT solution, the ADLIFE Toolbox. The target population is senior (55+) patients with severe Heart failure and/or COPD. In total in the seven pilot sites, 882 patients, 1243 caregivers and 577 healthcare professionals from specialized and primary care services will be involved in pilot operation and evaluation activities. Care delivery models, level of integration, scope and content of the Clinical Decision Support Services (CDSS) and health outcomes has been explored and defined involving relevant stakeholders at each pilot site. Results and Discussion Each pilot has identified improvement areas required to enable the delivery of care proposed in ADLIFE. A conceptual framework has been developed to that includes and categorize health outcomes. Data will be used for evaluation and CDSS. A set of PROMs has been proposed to capture the information on the effectiveness and the quality of the care delivered as perceived by the patients. CDSS are based on computable flowcharts as defined in evidence based clinical guidelines (single disease and reconciled for multimorbidity). AI algorithms will be developed and trained to identify Potentially Preventable Situations. Conclusions (comprising key findings) The project seeks to demonstrate that a personalized care model that integrates clinical and patient stakeholders´ analysis with ICT tools is effective and flexible and can be deployed and replicated in different health care systems. Lessons learned Assessing care models and having trusted personalised digital solutions are key for ADLIFE implementation and operation in the seven ICT health systems. Limitations Multimorbidity covers a wide range of conditions. ADLIFE focuses on COPD and/or Heart Failure with or without co morbidities. Further analytical and development work will be needed to be done. Suggestions for future research The effectiveness and efficiency of deploying digitally enabled holistic and integrated supportive care will be assessed by evaluating health gain, quality of life, use of resources and economic costs. The authors are on behalf of the ADLIFE Consortium. The ADLIFE project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 875209.