Self-Management of Complex Chronic Patients: Needs and A Proposal
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This document discusses self-management of complex chronic patients and proposes a self-management system. It notes that an aging population and increased chronic diseases are burdening healthcare systems. Chronic diseases are a leading cause of mortality, morbidity, disability, and healthcare expenditures in Europe. The CONNECARE project aims to develop a self-management system to facilitate active participation by patients in collecting health data to improve care through better diagnoses and therapies. The proposed system would support patients through physical activity monitoring, health monitoring, medication reminders, health advice, simple tasks, virtual visits, questionnaires, alerts, recommendations, and messaging with healthcare professionals.
Self-Management of Complex Chronic Patients: Needs and A Proposal
- 1. Self-Management of Complex Chronic Patients Eloisa Vargiu, Juan Manuel Fernández, Mauricio Gonzales-Gonzales, Juan Manuel Morales-Garzón, Kitiara Prunera-Moreda, and Felip Miralles Needs and A Proposal
- 3. 3 An ageing population and the increasing number of people with at least one chronic disease are demanding more resources and increasing the burden on health and social care systems Image: https://www.floptv.tv/flog/la-nuda-verita/pensionato-fugge-dalla-casa-di-riposo-per-fissare-un-cantiere/
- 4. Chronic diseases are the leading cause of mortality and morbidity in Europe, the major cause of disability, the principle reason why patients visit physicians, and the reason for 70% of health care expenditures Image: https://health.usnews.com/health-news/health-insurance/articles/2015-12-23/how-to-get-the-best-plan-when-you-have-a-chronic-illness
- 5. 5 Image: https://velvetchainsaw.com/2010/04/14/stomaching-long-conference-lectures-is-out-active-attendee-participation-is-in/ Facilitating new forms of active participation by patients and consumers in the collection of personal health data will improve the quality of care delivered to patients through better diagnoses and targeted therapies
- 6. Image: https://www.alliance-scotland.org.uk/blog/news/self-management-fund-review-2017/ Patient self-management plays an important role, especially when patients are elderly, widowed, and/or with economical-social restrictions
- 7. Clark et al. identified the main features to give support in chronic diseases by older adults Ref: Clark, N.M., Becker, M.H., Janz, N.K., Lorig, K., Rakowski, W., Anderson, L.: Self-management of chronic disease by older adults: a review and questions for research. Journal of Aging and Health 3(1), 3-27 (1991) maintaining exercises and activity levels monitoring physical indicators by objective means recognizing and responding to symptoms and controlling triggers to symptoms drug prescription and follow-up maintaining nutrition and dietary recommendations giving up smoking using strategies to relax and reduce stress managing emotions and psychological response to illness adapting to work interacting with healthcare professionals seeking information and using community resources managing relations with significant others managing alerts and emergencies
- 8. In CONNECARE, according to a co-design approach, generic requirements for a self-management system have been defined Three case studies Community-based prevention of unplanned hospital-related events in chronic complex patients with high risk for hospitalization Preventive patient-centered intervention in complex chronic patients undergoing elective major surgical procedures Pre-habilitation intervention in high risk candidates for major surgery Israel Catalonia Groningen Ref: http://connecare.eu/
- 9. Self-management in CONNECARE maintaining exercises and activity levels Physical activity Healthy lifestyles, including physical activity, have proven efficacy in the prevention and treatment of many chronic conditions Physical activity monitoring is done by relying to off-the-shelf activity trackers The following parameters have to be monitored: steps, distance (km), calories, and minutes of activity by intensity
- 10. Self-management in CONNECARE maintaining exercises and activity levels Health-status To better follow-up the status of a patient, several vital signs should be monitored depending on the disease and the associated co-morbidities: temperature; blood pressure; heart rate; weight; blood oxygen saturation; blood glucose level; and ECG. The professional prescribes when and with which frequency to make the measurement, as well as put thresholds to monitor anomalies Both the professional and the patient will receive alerts in case a given threshold has been overcome monitoring physical indicators by objective means
- 11. Self-management in CONNECARE maintaining exercises and activity levels Drug prescription Chronic patients are used to take several drugs during the day. Forget to take any may provoke serious problems The professional needs to prescribe all the drugs to be taken and the patient will receive a reminder any time s/he has to take one monitoring physical indicators by objective means drug prescription and follow-up
- 12. Self-management in CONNECARE maintaining exercises and activity levels Advices and training material Education is a really important issue to be provided to improve follow-up of a therapy and to empower the patient The professional can select advices and training material in form of text, images, or videos and the patient is asked to see it monitoring physical indicators by objective means drug prescription and follow-up advices and training material
- 13. Self-management in CONNECARE maintaining exercises and activity levels monitoring physical indicators by objective means drug prescription and follow-up advices and training material simple tasks Simple tasks Daily life activities performed at home radically improve patients' recovery Clinicians prescribes simple tasks to be performed during the day (e.g., dancing, cooking, reading) Depending on the disease and the kind of patient (e.g., in case of elderly people) the professional may ask to perform healthy activities such as drinking or eating a fruit
- 14. Self-management in CONNECARE maintaining exercises and activity levels monitoring physical indicators by objective means drug prescription and follow-up advices and training material simple tasks Virtual visits Several studies show the role of professionals and carers in supporting patients, especially when remote solutions have been adopted Virtual visits have been considered as a basic functionality to be provided Patients may stay more safely at home without needs to move to the hospital any time a recall visit is needed virtual visits
- 15. Self-management in CONNECARE maintaining exercises and activity levels monitoring physical indicators by objective means drug prescription and follow-up advices and training material simple tasks Questionnaires To empower patients is important to give them the possibility to fill one or more questionnaires Once filled a questionnaire, the patient has to receive a suitable message with the corresponding result At the same time, the professionals have to be automatically informed on the filled questionnaire virtual visits questionnaires
- 16. Self-management in CONNECARE maintaining exercises and activity levels monitoring physical indicators by objective means drug prescription and follow-up advices and training material simple tasks Notifications A reminder is sent before any required task (e.g., 15 minutes before taking the blood pressure) and a confirmation given after any performed task with suitable information (e.g., the value of the blood pressure) virtual visits questionnaires notifications
- 17. Self-management in CONNECARE maintaining exercises and activity levels monitoring physical indicators by objective means drug prescription and follow-up advices and training material simple tasks Alerts Anomalies are triggered any time data gathered from the patient (e.g., through the medical devices or a questionnaire) exceeds a given threshold defined at prescription time (e.g., a critical heart rate value) virtual visits questionnaires notifications managing alerts and emergencies
- 18. Self-management in CONNECARE maintaining exercises and activity levels monitoring physical indicators by objective means drug prescription and follow-up advices and training material simple tasks Recommendations All data gathered by the devices worn by the patient are automatically analyzed to give an intelligent support virtual visits questionnaires notifications managing alerts and emergencies sending recommendations
- 19. Self-management in CONNECARE maintaining exercises and activity levels monitoring physical indicators by objective means drug prescription and follow-up advices and training material simple tasks Messaging Similar to the well-known Whatsapp app, patients may send/receive text, images, videos, links, and documents virtual visits questionnaires notifications managing alerts and emergencies sending recommendations communicating with the professionals
- 20. The CONNECARE Self-Management System (SMS)
- 21. At the moment, about 40 patients have been recruited in the studies in the each of the 3 sites Adherence is good Improved self-Management of their conditions CONNECARE in the real world
- 22. The majority of elderly people do not use smartphone Those who do use old ones (few memory, few capacity) Needs of help for installations of app and devices Limited Internet connection at home Limited data availability when not at home Need of interaction to measure the vital signs Phone calls are preferred to messages Chronic patients self-management in the real world
- 23. 23 Before finishing…where is the AI?
- 24. AI in the CONNECARE SMS QoL assessment through a regression model approach Recommender system for physical activity (*) (*) Ref: J.M. Fernández, M. Mamei, S. Mariani, F. Miralles, A. Steblin, E. Vargiu, F. Zambonelli. Towards Argumentation-based Recommendations for Personalised Patient Empowerment. International Workshop on Health Recommender Systems, co-located with ACM RecSys 2017. August 31st, 2017, Como, Italy. CEUR Workshop proceedings Vol. 1953, pp. 2-5. Behavior recognition and user profiling System personalization
- 25. Thanks Gràcies This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 689802 Bedankt תודה Grazie Danke [email protected]