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Across the globe, the healthcare sector is experiencing transformations (cultural, social, digital and economic). This is due to the age and varying patient needs that are driving a shift in the healthcare landscape. At the same time, chronic diseases, social determinants and resource limitations continue to add pressure. Healthcare has thus shifted from paternalistic mode of care to patient centered care (PCC). The growing multiple divergent medical cases denote a need to collaboratively understand clinical issues and effectively determine the best course of action. With PCC, a patient is recognized as a unique human being before forming a diagnosis. This implies that there is a need for multifaceted decision-making. In this study, we use a co-construction participatory modeling approach to understand the complexities in collaboratively managing knowledge for multi-morbid chronic patients on Advance Care Plan (ACP). To achieve this, focus group discussions (FGD) with 12 participants (five healthcare professionals, three health managers and three healthcare key decision makers) from Basque Public Health System (Osakidetza), in Spain were involved in identifying the key challenges and developing a systemic thinking model. As a result, three key challenges were identified i.e. 1) culture (citizens are not willing to talk about death, 2) healthcare professionals’ challenge to change attitude and perspectives, and 3) changing the current system towards holistic and a shared care model. From the developed Causal loop diagrams (CLDs), it is noted that perpetuation of fragmented and paternalistic care is likely to get worse without recognition of the ACP as a social need and a crucial part of the clinical practice part change.

Due to population ageing and medical advances, people with advanced chronic diseases (ACD) live longer. Such patients are even more likely to face either temporary or permanent reduced functional reserve, which typically further increases their healthcare resource use and the burden of care on their caregiver(s). Accordingly, these patients and their caregiver(s) may benefit from integrated supportive care provided via digitally supported interventions. This approach may either maintain or improve their quality of life, increase their independence, and optimize the healthcare resource use from early stages. ADLIFE is an EU-funded project, aiming to improve the quality of life of older people with ACD by providing integrated personalized care via a digitally enabled toolbox. Indeed, the ADLIFE toolbox is a digital solution which provides patients, caregivers, and health professionals with digitally enabled, integrated, and personalized care, supporting clinical decisions, and encouraging independence and self-management. Here we present the protocol of the ADLIFE study, which is designed to provide robust scientific evidence on the assessment of the effectiveness, socio-economic, implementation, and technology acceptance aspects of the ADLIFE intervention compared to the current standard of care (SoC) when applied in real-life settings of seven different pilot sites across six countries. A quasi-experimental trial following a multicenter, non-randomized, non-concurrent, unblinded, and controlled design will be implemented. Patients in the intervention group will receive the ADLIFE intervention, while patients in the control group will receive SoC. The assessment of the ADLIFE intervention will be conducted using a mixed-methods approach.

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.

The number of patients with multimorbidity has been steadily increasing in the modern aging societies. The European C3-Cloud project provides a multidisciplinary and patient-centered "Collaborative Care and Cure-system" for the management of elderly with multimorbidity, enabling continuous coordination of care activities between multidisciplinary care teams (MDTs), patients and informal caregivers (ICG). In this study various components of the infrastructure were tested to fulfill the functional requirements and the entire system was subjected to an early application testing involving different groups of end-users. MDTs from participating European regions were involved in requirement elicitation and test formulation, resulting in 57 questions, distributed via an internet platform to 48 test participants (22 MDTs, 26 patients) from three pilot sites. The results indicate a high level of satisfaction with all components. Early testing also provided feedback for technical improvement of the entire system, and the paper points out useful evaluation methods.

Introduction: A growing share of the population in OECD countries is of age 65 and over, expected to reach 22% by 2030 (compared to 15% in 2010). Life expectancy has also significantly increased. People at age of 65 are expected to live for an average of 21 and 17 years for women and men; an almost 40% increase since 1960. The profound success in improving life expectancy has resulted in a new set of challenges.\ud \ud Challenge: Shift of resources was necessary, redirected to address the complex needs of multi-morbidity patients. Furthermore, patients’ needs are not effectively met by current care models, which tend to operate in isolation. This results in static services that patients need to wander. It is common for patients to revisit all levels of care discussing their needs, and reconciling potentially conflicting objectives amongst their conditions (e.g., incompatible lifestyle goals, adverse drug effects and side-effects, undetected conditions). Optimal collaboration and coordination between professionals in the delivery of integrated care have become essential requirements for the provision of high-quality care. Coordinated care aims for the orderly arrangement of individual and group efforts providing unity of action in pursuit of a common goal.\ud \ud Method: C3-Cloud is an e-health based ICT system, offering integrated, patient-centred care, considering all aspects of multi-morbidity and creating a collaborative environment, for all involved stakeholders. The navel of the system consists of the patient care plan, a digital shared picture of the patients’ needs and care regime. The care plan allows all professionals to review and understand the implications of one condition in the presence of others; this by its nature is complex, containing a considerable amount of diverse information. Navigating, understanding, and interpreting all the information can be confounding. The C3-Cloud Clinical Decision Support Service (CDS) offers an automated means of interpreting the available data. CDSS connects to the care plan repository, and continuously searches records for relevant data. The algorithms and integration of recommendations to the service were reviewed and validated by clinicians. Human computer interaction methods were employed to ensure optimal interaction between C3-Cloud and its users.\ud \ud Results: C3-Cloud offers CDSS for diabetes, renal failure, depression and congenital heart failure, with over 300 rules and checks that deliver four best practice guidelines in parallel; whilst reconciling their objectives, and monitoring their outcomes. It creates warnings or recommendations for the patient as well as for formal and informal carers.\ud \ud Discussion and Conclusions: C3-Cloud offers a powerful way to ensure that subtle, as well as critical, information about the patient, is presented to healthcare professionals, along with guideline based recommendations. The rules reconcile potential conflicts amongst conditions. Combined with a single patient and professionals interface, it provides a seamless experience throughout the health and care service. The C3-Cloud CDS service provides support to three pilot sites throughout Europe, currently undergoing evaluation.\ud \ud Acknowledgements: C3-Cloud is funded from the EU Horizon 2020 research and innovation project C3-Cloud, under grant agreement No 6891810.\ud \ud This abstract is based on the work and material of the entire C3-Cloud consortium.

Our POC (Point of Care) device is intended to be a diagnostic tool for routine use in the clinical sector. The validation of the whole procedure, including bacterial genomic DNA isolation and the Real Time detection of Salmonella spp., was conducted on 29 clinical stool samples that had been diagnosed with Salmonella spp. by a routine culture technique. The entire process was achieved in a single microfluidic chip within 35 min. In comparison to the culture reference method that is used in the clinical laboratories, this new device performed well in regards to the analytical parameters of sensitivity, specificity and accuracy. Therefore, the POC device reported in this study proved to be very appropriate for the fully integrated analysis system. To the best of our knowledge, this is the first work to report the sample preparation and followed by Real Time PCR (Polymerase Chain Reaction) on a single 2.5 μl chamber chip for the detection of Salmonella spp. bacteria in stool samples.

An electrochemical DNA sensor based on the hybridization recognition of a single-stranded DNA (ssDNA) probe immobilized onto a gold electrode to its complementary ssDNA is presented. The DNA probe is bound on gold surface electrode by using self-assembled monolayer (SAM) technology. An optimized mixed SAM with a blocking molecule preventing the nonspecific adsorption on the electrode surface has been prepared. In this paper, a DNA biosensor is designed by means of the immobilization of a single stranded DNA probe on an electrochemical transducer surface to recognize specifically Escherichia coli (E. coli) 0157:H7 complementary target DNA sequence via cyclic voltammetry experiments. The 21 mer DNA probe including a C6 alkanethiol group at the 5' phosphate end has been synthesized to form the SAM onto the gold surface through the gold sulfur bond. The goal of this paper has been to design, characterise and optimise an electrochemical DNA sensor. In order to investigate the oligonucleotide probe immobilization and the hybridization detection, experiments with different concentration of DNA and mismatch sequences have been performed. This microdevice has demonstrated the suitability of oligonucleotide Self-assembled monolayers (SAMs) on gold as immobilization method. The DNA probes deposited on gold surface have been functional and able to detect changes in bases sequence in a 21-mer oligonucleotide.

An introduction: (comprising context and problem statement) The high prevalence of patients with complex needs is an increasingly worrying reality in health systems. The most characteristic features of the current healthcare model are the fragmentation of care levels, the lack of coordination, integration and continuity in patient care, leading to problems of inappropriate use of human and economic resources and health services. The problem requires a coordinated response comprising all stakeholders involved. Short description of practice change implemented: The European Carewell project http://www.carewell-project.eu/home.html aims the design and implementation of new organizational models of integrated cost-effective care, addressing multimorbid patients, in order to improve care and healthcare through: 1) the coordination and communication among health professionals, and 2) the patient-centered care based on empowerment of the patient (and their caregiver) and the monitoring of their health status. The project uses ICTs as enablers for the implementation of such interventions. Aim and theory of change: The main objective of Carewell is the design, implementation and evaluation of the impact of an integrated healthcare model for multimorbid patients, in terms of quality of care, efficiency and satisfaction of professionals and patients Targeted population and stakeholders: The target population was elderly (≥ 65) patients having at least two of the chronic diseases included in the Charlson comorbidity index and being one of them CHF, EPOC or diabetes mellitus. In the Basque Country a population of around 6200 patients have benefited from the new integrated care pathway whereas only 200 patients (104 intervention and 100 controls) have been included in the evaluation. These patients have been followed up for a minimum of 9 months. There are 13 integrated care organizations (ICOs, primary and secondary care) in the Basque Country. 6 out of the existing 13 have been involved in the project. A multi-disciplinary, collaborative and inter-organizational team, which consisted in 130 health professionals and 58 social workers from distinct ICOs, was created to define and deploy the new care pathway. Timeline: The project started in February 2014 and phases completed are: - Definition of the new integrated care pathway: February-December 2014 - Preparation of the piloting (professional engagement and training): January-April 2015 - Piloting: May 2015-September 2016 - Evaluation: October-December 2016 Highlights: (innovation, Impact and outcomes) Innovation: A new organization model for the care of multimorbid patients has been defined,developed and deployed. Several elements have been identified as key factors: integrated care pathways agreed by all stakeholders, decision support tools, ICT services, training of professionals, development of an structured empowerment program for patients and caregivers (Kronik-ON) and a new mathematical model to predic sue of resources in mid-long term ("Predictive Modeling"). Impact: In the Basque Country the new organizational model has had an impact on the provision of services to multimorbid patients. Through the prevention and promotion of health, as well as the empowerment of patients, it has promoted a transition from specialized and hospital care to primary care. Outcomes: Clinical effectiveness, economic analysis and the patient's and professionals´ perspectives have been assessed by quantitative and qualitative approaches. Satisfaction of both professionals and patients/caregivers has been demonstrated, whereas the profile of the use of services has moved from secondary care to primary. In fact, then number of hospitalizations and ED visits has decreased and the GP contacts have augmented. Comments on sustainability: The intervention in the Basque Country has used the human and technological resources currently available in Osakidetza (Basque Health Public System), which favors and facilitates any subsequent deployment. Predictive analysis has confirmed that intervention is cost effective. Comments on transferability: The results of the evaluation of the new organizational model have been positive, which has led to its imminent extension to other ICOs of Osakidetza. Conclusions (comprising key findings) and lessons learned: -A detailed methodology for the design of the intervention is crucial -Multidisciplinary teams should represent all stakeholders in order to consider their perspective in the definition of new care pathways. -New pathways must be integrated into the daily practice. -the service must be flexible to be adopted in new contexts -New roles are necessary which requires reorganization of tasks -Training of professionals is crucial to promote the development of new skills -Technology is essential for facilitating coordination among health professionals -Involvement of top managers of the organizations enhances the engagement of healthcare professionals, favoring the implementation of new procedures -Primary Care is responsible for proactive control of the patients -Nursing role is essential in the empowerment of the patient/caregiver Discussions: It is fundamental to align the project objectives with the strategic plan of the central organization to ensure that the deployment of the intervention is a priority. However, top-down support is not enough, meso-level managers and front-line professionals have to believe in the project, so both interests converge. Continuous improvement methodologies are of great relevance identify weaknesses in a regular basis and apply new solutions. To do so, it is mandatory to establish a consolidate monitoring and assessment procedures.

Introduction : One of the distinctive characteristics of frail elder patients with comorbidities is the complexity of the health and social needs they present as well as their vulnerability and high risk to develop dependence and high services consumption. The provision of healthcare to these individuals should be able to respond to their complex needs in order to improve their health status and to prevent avoidable resource consumption and suffering. Integrated care may be an adequate strategy to achieve this goal. The CareWell Project, co-funded by the European Commission, is aimed to assess the impact of new organisational models to provide ICT supported integrated healthcare (IHC) to frail elderly patients with comorbidities. The overall aim of the evaluation carried out in CareWell is to assess the impact of the implementation of ICT supported integrated healthcare. Evaluation will be conducted using the MAST multi-dimensional evaluation methodology adapted to the needs of CareWell project, focusing on integrated healthcare. MAST includes assessment of the outcomes divided into the following seven domains: 1) Health problem and characteristics of the application; 2) Safety; 3) Clinical effectiveness; 4) Patient perspectives; 5) Economic aspects; 6) Organisational aspects; and 7) Socio-cultural, ethical and legal aspects . This communication will be focused on the baseline assessment of the recruited subjects. Methods : CareWell is a quasi-experimental study with a control group, targeting community-dwelling frail subjects suffering from one of the following disease: chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) (both insulin-dependent and noninsulin-dependent) or chronic heart failure (CHF) as well as one other comorbidity. Subjects in the intervention group have received the IHC and the control group, the usual care provided by their health system. The project is being developed in six pilot sites through Europe. All pilot sites have conducted a baseline assessment of the study population prior to the deployment of the new organisational model, which will serve as the basis for comparison (usual care), and again at the end of the follow-up, one year after the deployment (new care). Descriptive analysis have been performed for each variable included in this study using mean and standard deviation for quantitative variables, and frequencies and percentages for categorical variables. Variables collected in the basal assessment include socio-demographic variables (age, sex, education level, occupation, income); health related habits (alcohol and tobacco consumption, physical activity); health status (comorbidities, functionality status using Barthel Index, mental health status using Geriatric Depression Scale); and self-perceived experience with care provision measured by PIRU Questionnaire. Results : Overall, 859 care recipients have been recruited for the Carewell project. Of these, 477 have been assigned to the intervention group. Patients were equally distributed regarding gender (50.5% of men), with a mean age of 77.6, 95% CI (77.1, 78.1). The most frequent disease in the project population was DM (66.4%) followed by CHF (61.8%) and COPD (54.1%). The care recipients have a high degree of independence with a Barthel index median of 100, IQR (80,100). Conclusions : Evaluation of integrated healthcare service delivery processes will improve the current scientifically based knowledge on barriers and facilitators towards integrated healthcare delivery.

This paper describes how sixteen partners from eight different countries across Europe are working together in two EU projects focused on the development of a point of care system. This system uses disposable Lab on a Chips (LOCs) that carry out the complete assay from sample preparation to result interpretation of raw samples. The LOC is either embedded in a flexible motherboard with the form of a smartcard (Labcard) or in a Skinpatch. The first project, OPTOLABCARD, extended and tested the use of a thick photoresit (SU-8) as a structural material to manufacture LOCs by lamination. This project produced several examples where SU-8 microfluidic circuitry revealed itself as a viable material for several applications, such as the integration on chip of a Polymerase Chain Reaction (PCR) that includes sample concentration, PCR amplification and optical detection of Salmonella spp. using clinical samples. The ongoing project, LABONFOIL, is using two results of OPTOLABCARD: the sample concentration method and the capability to fabricate flexible and ultra thin LOCs based on sheets instead of wafers. This rupture from the limited and expensive wafer surface heritage allows the development of a platform where LOCs are big enough to include all the sample preparation subcomponents at a low price. These LOCs will be used in four point of care applications: environment, food, cancer and drug monitoring. The user will obtain the results of the tests by connecting the Labcard/Skinpatch reader to a very popular interface (a smartphone), creating a new instrument namely "The SmartBioPhone". All standard smartphone capabilities will be at the disposal of the point of care instrument by a simple click. In order to guarantee the future mass production of these LOCs, the project will develop a large dry film equipment where LOCs will be fabricated at a low cost.

Introduction: The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. C3-Cloud project aims to build an integrated care platform for addressing the growing demand for improved health outcomes of multimorbid and long-term care patients. Theory/Methods: C3-Cloud has established an ICT infrastructure enabling continuous coordination of patient-centred care activities by a multidisciplinary care team MDT and patients/informal care givers. The Coordinated Care and Cure Delivery Platform C3DP allows, collaborative creation and execution of personalised care plans for multi-morbid patients through systematic and semi-automatic reconciliation of clinical guidelines. Clinical decision support CDS systems implementing flowcharts from evidence based clinical guidelines are integrated to present suggestions for treatment goal and activities e.g. medications, follow-up appointments, diet, exercise, lab tests. Pilot site local care systems are integrated with the C3DP via the technical and semantic interoperability platform to facilitate informed decision making. Active patient involvement is realized through a Patient Empowerment Platform presenting personalized care plan to the patient and establishing a continuous bi-way communication with the patient to collect patient observations, questionnaire responses, symptoms and feedback about care plan goals and activities. Results: The following research results have been achieved to enable guideline enabled personalised care plan management for addressing the needs of multi-morbidity: 43 logical flowcharts were designed out of 4 disease guidelines Type 2 Diabetes, Heart Failure, Renal Failure and Depression. 181 CDS rules assessing 166 patient criteria and recommending 154 goal/activity suggestions were implemented as CDS services in GDL covering T2D and RF. 52 reconciliation rules were designed for eliminating contradicting guideline recommendations due to multi-morbidity. 23 HL7 FHIR profiles were defined for representing care plan and patient data. C3DP has been integrated with these CDS services via CDS-Hooks specification to recommend personalised care plan goals and activities. Discussions: In this research, we have successfully implemented an ICT infrastructure enabling guideline-driven integrated care for multi-morbid patients. Although our ICT solution covers all the technical requirements identified by clinical partners, effective implementation of integrated care in real-life care setting requires major changes in organisational responsibilities and care pathways. Conclusions: User-centred design and usability testing have successfully been completed. C3-Cloud pilot application will now be operated in 3 European pilot sites with the participation of 62 MDT members and 1200 multi-morbid patients for 15 months. Lessons learned: There are two main research lines for reconciliation of contradicting guideline recommendations: 1 fully-automated reconciliation via ontology reasoning, 2 manually-crafted reconciliation rules by clinical expert groups. Although first approach is more dynamic, research results are still for very primitive cases and not clinically validated. As we are targeting an industry-ready solution after piloting in real-life settings, we have opted for the second option. Limitations: When a new chronic disease is to be addressed within our platform, reconciliation rules covering all disease combinations have to be re-assessed by the clinical expert group. Suggestions for future research: Fully-automated reconciliation approaches need to be further studied and validated in real-life settings.

Introduction: The C3-Cloud project http://c3-cloud.eu/ aims to enable the development of personalised care plans for multi-morbid conditions, supported by innovative ICT components, to improve delivery of integrated and patient-centred care. This is achieved through the coordination by a multidisciplinary care team MDT. To demonstrate feasibility, pilot studies will be conducted in 3 European regions: Region Jamtland Harjedalen RJH, Sweden, South Warwickshire SWFT, UK and Basque Country BC, Spain. Short description of practice: We describe the pre-implementation phase to support the implementation of the C3-Cloud care model during the pilot study. The results comprise of prototypes that will be tested in each site. They include: i organizational model description in C3-Cloud scenario, ii key factors at system level and care coordination iii relation between actors, activities and C3-Cloud solutions. Aim and theory of change: The aim is to define organizational prototypes in each site. The theory of change is based on the identification of the organizational model changes required for C3-Cloud solutions to work consistently across different organizational settings and population groups, accordingly to C3-Cloud care model. Targeted population and stakeholders: Multimorbid patients who are 65+ and have at least two or more of diabetes, heart failure, renal failure and depression. 600 intervention and 600 control patients and 62 MDT members. MDT is comprised of health professionals, social care workers and homecare providers. Timeline: The study is divided into a pre-study phase, a study phase and a post-study. This work has been developed in pre-study phase. Highlights: The analyses of system factors have shown differences among the three sites, in various domains, as the resources of the community. The implementation of C3-Cloud speeds up communication among actors. The patients participate in a higher number of activities and the teamwork is strengthened. C3-Cloud supports the formal introduction of all actors in the preparation of the work plan and increases patient involvement. Sustainability: We will use the human resources available in the settings and the technological resources generated along the project, facilitating subsequent deployments. Transferability: It will be supported by the development of guidelines for any organisation to implement the necessary changes. Conclusions: The three pilot sites have good health systems that comply with most of the organizational model prototype requirements. Organizational and geographical settings and place of service for interventions are defined. Care coordination actors, activities and interpersonal communication are in place. However, several areas as alignment of incentives and patient involvement require further research for C3-Cloud care model. Discussion: With the information collated to date, pilot sites are carrying out further work to develop the capability identified infrastructure, skills and organizational practices to provide the C3-Cloud model care. The aim is to implement the suggested changes to adequately deploy the pilot phase of the project in the three environments. Lessons learned: The contribution of MDT members and patients has been crucial. The involvement of the patient in all aspects of care is key for successful care. Change management has to consider what is currently possible for integrated multi-morbidity care pathway adoption.

Introduction: (comprising context and problem statement) There is an increasing need to organise the care around the patient and not the disease, taking into account his or her multiple physical and psycho-social conditions. An integrated, patient-centred care and cure delivery architecture needs to be developed considering the realities of multi-morbidity and poly-pharmacy. This needs to address the medical, technological, organisational and socio-economical challenges of creating a collaboration environment for all of the stakeholders involved in the holistic continuum of care. Short description of practice change implemented: The project C3-Cloud (H2020, PHC-25-2015, 689181) aims to enable the development of personalised care plans for multi-morbid conditions supported by innovative ICT components to improve delivery of integrated care services to elderly patients with multi-morbidity through continuous coordination of patient-centred care activities by a multidisciplinary care team (MDT). It is undertaking the design and development of: (i) Personalised Care Plan Development Platform & Coordinated Care and Cure Delivery Platform managed by a coordinated multidisciplinary team, (ii) Clinical Decision Support Modules enabling risk stratification, poly-pharmacy management and goal setting and monitoring and (iii) Patient Empowerment Platform facilitating and fostering the involvement of the patient and his informal care givers. Aim and theory of change: The applicability of this C3-Cloud integrated care approach and supporting set of innovative ICT components will be demonstrated in varying clinical, technological and organisational settings by piloting in three European regions (South Warwickshire, Basque Country and Region Jamtland Harjedalen) with quite different health and social care systems and ICT landscapes. Then new organisational models for addressing multi-morbidity will be proposed by identifying the best practices in different deployment settings. Targeted population and stakeholders: The target population for the C3-Cloud pilot applications is elderly (65+) patients, having at least two among these four chronic diseases: heart failure, renal failure, diabetes and depression. In total in the 3 pilot sites, 150 patients for intense evaluation in exploratory trial, 600/600 patients for resource monitoring to support large-scale impact assessment and 62 multidisciplinary care team members composed of health professionals, social care workers and homecare providers will be involved in pilot operation and evaluation activities. Timeline: The project is running for 48 months, from May 2016 to April 2020. The main phases are: Conceptual design of the C3-Cloud System Architecture according to pilot applications’ requirements, May 2016-December 2016 Exploration of new patient pathways and organisational models for improved delivery of integrated care: May 2016-April 2017 Development and testing of ICT components: January 2017-June 2018 Preparation of exploratory trial: November 2017-October 2018 Exploratory trial: 15 months long pilot operation: November 2018-January 2020 Evaluation: January 2019-April 2020 Highlights: (innovation, impact and outcomes) A thorough review of the state of the art has provided a comprehensive survey of currently available standards, technologies and architectures in the field of advanced ICT systems and services for integrated care, that have helped to support the design of the C3-Cloud architecture. The conceptual design of the C3-Cloud architecture has been finalized based on the results of pilot application user requirements and the scientific and technical requirements. Currently we are defining the existing organizational models in each pilot site and their graphical representation. Then through a self-assessment exercise, each pilot is going to identify its improvement areas in order to achieve the organizational model enabling the C3-Cloud delivery of care. The key elements will be identified at the end. The evidence based clinical guidelines for targeted individual chronic conditions have been identified and represented as flowcharts. Then guidance will be developed on how individual clinical guidelines can be reconciled for the automation of personalised and integrated care plan development. Comments on sustainability: The intervention in the pilot sites will use the human resources available in the three settings and the technological resources generated along the project, which will facilitate subsequent deployments. The consortium of the project is really concerned to develop sustainability strategies for the results obtained during the project. Comments on transferability: Starting from the evidence of risks and complications from today’s delivery of care in disease silos, and the requirements of the identified new generation integrated care pathways, the implications for scaling up adoption are being examined. This includes generalizing the architecture to other long term conditions. Special focus is being put on the transferability of the new organisational models supported by the development of guidelines for smooth management of necessary changes and taking into account diversity of European national and regional systems. Conclusions: During the lifetime of C3-Cloud project, new patient-centred pathways focused on integrated and collaborative care and cure will be developed and experienced with the participation of all stakeholders and innovative ICT tools. These new pathways will require new organizational models to enable their management and implementation. All these outcomes supported with change management guidelines and lessons learned will be shared with the European community. Acknowledgements: The C3-Cloud project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 689181.