Multi-chronic elderly patient management including polimedication

Several sensing technologies, available in the GK Things Catalogue, can be leveraged and integrated in an unobtrusive mobile data collection platform (e.g. based on smartphones, smart-trackers, smart-textiles, etc.), able to monitor the multiple parameters required in Chronic Care Models (CCM) for multi-morbid subjects. Through the GK Healthcare Space, data can be shared with clinical professionals in charge of managing the CCMs, in order to adjust individual care plans accordingly. Through the GK Ecosystem Transaction Space, robotics KETs (from very simple pill dispensers to more complex social robots [26]) can be integrated with digital coaching systems to assist polymedicated patients (e.g. in particular for patients which are concurrently affected by cognitive impairments).

Target population:

Targets elderly chronic patients with variable complexity according to GK’s risk stratification pyramid. There are significant differences among sites on the preliminary inclusion / exclusion criteria, which reflect the specificities of the planned interventions. For instance, the planned minimum age for inclusion varies from 50 years in Aragon, Cyprus, Poland or Saxony up to 70 years in the Basque country. Similarly, the scope of the use case varies notably across sites, with Saxony focusing on psychological and social aspects, and thus the target population will have suspected mental health impairment; Poland targeting exclusively the problem of effectively managing polymedication; and, as a last example, Cyprus implementing a program exclusively for cancer patients

Key enabling technologies:

  • Wearables/medical devices, intended to monitor and track key variables such as drug adherence, physical activity, falls, sleep patterns, pain, oxygen saturation, blood pressure, heart rate or SpO2 (all sites). 
  • Home sensors/robots permanently assessing the house for risks, learning the position of objects of daily use and monitoring the activities of the patient, suggesting activities, and, when needed, requesting telepresence support (Milton Keynes). 
  • App for smartphone or tablet/online platform, enabling self-management, healthy lifestyle promotion, fostering medical education and health literacy, adherence to medication and control of polymedication, or social Engagement, and allowing regular follow up of patients through their interaction with a digital coach or chatbot (all sites). 
  • Professional’s online platform/dashboard, providing overview of alarm signs and/or relevant information (all sites).