Associated Pilot "EIC-IL" in Netherlands

Motivation for the Proposal

The Eindhoven hospital Maxima Medical Centre has recently opened FLOW, its new Integrated Care Centre (http://bit.ly/1zi3o9l). This centre has been set up to combine and integrate all care that is needed to support patients with multi-morbidities. One of the target groups is the patient with diabetes or COPD that also have acute heart conditions.

Rehabilitation of these patients at home is complex, since these patients are often less motivated to maintain a new lifestyle, prescribed by the cardiologist, dietician, psychologist and physical therapist. Often they do not follow the needed exercise at home, nor do they stop smoking or eating less healthy food.

In a new setup of integrated care and support of independent living, the heart patients will be monitored & supported at home via ReLifE services (Regional Life Management Ecosystem) and its array of services and technologies: remote sensor/device monitoring & analysis, such as recording of physical activity via heart rate sensors and accelerometers, screen2screen video communication between stakeholders, self-care modules, and several social care support programmes.

In addition, the patient will be stimulated to see his own data and understand/monitor his physical progress, eventually also anonymously compared to other peers’ progress. All the professional stakeholders of the specific ReLifE programme, (i.e. cardiologist, GP, home care worker, dietician, psychologist and physical therapist) will work in an integrated multi-disciplinary coaching team in FLOW, the new regional integrated care centre. This means that they need much more frequent contact, both face-to-face and remotely.

If the care-recipients have computer experience, they will get online access to the new services via their own computer. If they have no computer experience at all, they will also get a touchscreen, including an intuitive personal portal interface application, something, which is quite important in the early days of recovering. Patients also get a Raspberry-Pie-based home gateway device, which is to act as an intermediary data storage and sensor gateway device. Working with the universAAL platform would mean that connecting new home applications and/or remote services to the ecosystem would become easier and cheaper, as communication with the devices will be abstracted, hereby avoiding vendor lock-in.

Piloting Concept

Description

This Eindhoven Regional pilot adds (1) social care to the existing (2) clinical and (3) tele-healthcare of heart failure & revalidation recovering patients. All three levels of care are to be integrated based on the same Personal Data / Life Management ecosystem Infra+Infostructure but obviously cater for different services. Notably the sensor / device involved in tele-monitoring integrated care, will be abstracted by integrating the universAAL modules in the home gateway and the ReLifE cloud platform.

universAALising the Eindhoven Independent Living Pilot

Value Proposition

  • One care – One platform: integrated care at its fullest

  • The patient as stakeholder in his own processes and the ethical integration point of his own data.

  • universAALised modular portal interfaces and device/sensor connectivity.

  • Powerful trust-based distributed ecosystem network for streams and data.

  • Open portal of interoperable universAALised services via ReLifE API store

Value Chain – Stakeholders

  • MMC: The flow integrated care centre setup by the regions hospital MMC, to be extended to an inter-hospital cooperation platform. FLOW is responsible for the patient management.

     

  • Synergetics: ecosystem infra-infostructure for clinical and tele-health service now being extended into the home using social care.

  • MiBida: home portal for patients offering their known and trusted interface / services

Deployment Plan

Activities

  1. universAALise devices/sensor communication between home/care to the ReLifE cloud data/analytics platform. both endpoints: (1) the MiBida Home Gateway, which runs on Raspberry Pie will be extended by integrating specific Raspberry Pie universAAL component. (2) The ReLifE cloud will be enhanced using the universAAL Linux component, and notably with the ontology for semantic mapping of device / sensor data: Jan - April

  2. Going through ReAAL “lab tests” for about two months: March- April

  3. Doing “site tests” (real-life but controlled test in the pilot site with few voluntary end users) to make sure that everything is prepared well for the roll-out of the universAALized application in real life. These tests will run in parallel with the already planned integrated care pilot with FLOW, which will tele-monitor 500 heart failure recovery & revalidation patients: April-May

  4. One or more iterations of expansions to the whole set of planned users, including the subtasks for installation, configuration / customisation, training and user mentoring, and on-site support: May

  5. Social Care Services: Social carers will be involved in supporting / motivating the patient in his revalidation. Using SSO, the social carer will have access the consented and needed data and services to support the patient

  6. Performing the evaluation activities defined by ReAAL parallel to all the above activities. This activity will be performed by the FLOW team and be integrated into the Flow integrated care centre method.

User Planning

User Planning

In total 200 patients will get integrated clinical, and social care services:

  • Screen-to-Screen video communication using WebRTC

  • HL7 v3 and Detailed Clinical Model support data services.

  • Integrated Sensor Analytics dashboards << which are universAALised.

Patients are supported by formal FLOW carers and by informal homecare carers and this for well over 350 users.

This results in a total of 550 users. To have a buffer for possible changes, EIC/IL targets a minimum of 420 users by assuming only one informal carer per patient and one forma carer per 10 patients.

Resource Planning and Cost Estimation

The following diagram summarizes the time planning and the task assignment to the involved partners. The related planning of the person-months and the associated costs can be found in section 3.