OPTIMAL: The OPTimized e-care model for Individuals with Multi-morbidity And Long-term needs

The 10% most costly patients consume approximately 2/3 of all healthcare resources. This group is made up of an increasing number of patients with multiple Long Term Conditions (LTC). The quality of care for LTC-patients is challenged by complex care processes, each involving multiple care providers, organizations and specialties, over long periods of time. The principles of the Chronic Care Model (CCM) are considered best practice in this area. Although CCM underlines the importance of use of ICT-tools, most CCM projects have negligible ICT-support. There is an urgent call to create ICT-solutions that support changes in both the design and quality of care for LTC patients. OPTIMAL virtual e-care delivers the triple aim of improved health and function, better care experiences, and reduced costs. The OPTIMAL solution builds on a foundation of trust that outlines the ethical, legal and societal requirements of a virtual care system. On this foundation we construct digitally mediated wellbeing, health and medical services: 1) extensive collection/ extraction and harmonization of relevant health data from legally available sources 2) privacy preserving analyses which detect increased risk for the individual and/ or patient groups 3) Context sensitive decision support for both patients and providers, when risk is elevated 4) Tools for virtual team-based collaboration and communication which includes the patient, 5) Tools for patient self-management support and medical diagnosis/ treatment in the patient home environment. We build on a long-term commitment of a national and international research and development network with patient representatives, health/ ICT-frontline professionals, and health/ICT system managers. The pre-project will outline the OPTIMAL health- and ICT-innovation process in 3 workshops that defines a common vision, articulate the ICT-challenges that need to be solved, and the organizational, budgetary and management principles of the project.