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Coherent care plans for patients with multiple, co-occurring chronic conditions

Better coordination of care plans between healthcare sectors is high on the European health agenda. So is efficient management of the steadily rising number of patients with co-existing chronic conditions. The PICASO project aims to develop information and communication technologies which meet these demands, by supporting a continuum of care from hospitals and outpatient clinic to the home:

- The PICASO platform will enable the sharing of a patient's complete care pathways with tools to establish health status, predict risks and adjust care. Based on monitoring of different physiological parameters at home, the patients can actively participate in their own care. The result is better management of co-existing diseases and coordination of care plans for the benefit of patients and carers across organisations, explains Project Coordinator, Dr. Markus Eisenhauer from Fraunhofer Institute for Applied Information Technology.

Trials in Italy and Germany
To demonstrate the platform and its wide applicability, the technologies will be trialled in two different national settings with two different patient groups, counting up to a 100 patients: in Italy, the University Hospital of Tor Vergata in Rome will enrol patients with Parkinson's disease and in Germany, the University Hospital of Düsseldorf will engage patients diagnosed with Rheumatoid Arthritis. Both patient groups have Cardiovascular Diseases as co-morbidities and both settings share the complexity of treating co-occurring diseases:

- Clinical treatment of people with co-morbidities is much more complex than treatment of patients with a single condition since treating one chronic condition can have negative effects on another. The treatment is also very individual and patients have to work closely with doctors and therapists to establish a suitable patient programme, accommodating the patient’s particular and changing needs. PICASO can support the management of these programmes which involves different disciplines, multiple care channels and actors, explains Dr. Agostino Chiaravalloti from the University Hospital of Tor Vergata.

LinkWatch in the home
To involve the patients in their own care, patients will be equipped with sensors at home to measure different physiological parameters such as blood pressure and heart rate using the LinkWatch care platform. Measurements can also include time in bed and falls and contextual information such as temperature and air quality. Patients can monitor their own health status by following the data and results via the LinkWatch GUI. Information can also be accessed by the care providers for decision support.

About the project
The PICASO project is co-funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement No 689209 and finishes in January 2019. It constitutes nine organisations from seven different countries, mixing clinical, technological, societal, academic and business expertise.

Visit the project

Read more about LinkWatch