The TransCare project is about following up patients at home after discharge from hospital and reducing the number of readmissions. This will be done by monitoring patients at home, providing information to the patient about the disease, recommended diet and exercise, and assessing the progress of rehabilitation.
TransCare is part of the EU THCS programme (THCS = Transforming Health and Care Sector). The participating countries are Norway, Italy and Romania. For the Norwegian participants, the project is financed by their own efforts and by the Research Council of Norway.
In Norway, Farsund Municipality, Tellu AS and Karde AS are participating in the project. From Italy, INRCA (Istituto Nazionale di Ricovero e Cura per Anziani), a leading geriatric clinic that runs several research hospitals spread across the country, is participating. Romania is participating with the coordinator Technical University of Cluj-Napoca (TUC) and one of the country's most important heart clinics, HINS (Heart Institute Niculae Stancioiu).
The participating countries have very different systems for following up patients after discharge from hospital. In Norway, the municipalities have a main role in follow-up, in Italy the hospital is responsible, while in Romania the family and relatives play the main role. One goal of the project is to investigate whether parts of solutions in one country can be reused in another.
In the first phase of the project, until October 2025, technologies have been further developed by Tellu, Karde and TUC. The user organizations Farsund municipality, IRCA and HINS have redesigned their patient journeys to include digital tools and solutions to improve communication, coordination and patient engagement during the transition from hospital to home.
Tellu provides the sensor-based monitoring infrastructure, as well as the administration and user interface for healthcare professionals. This is built on the TelluCare platform and its patient monitoring service.
The TelluCare platform provides health and care services used by municipalities and hospitals. It includes secure authentication. Together with fully encrypted data storage and role-based access control, it meets all security requirements for healthcare services. The system has a comprehensive web interface for healthcare professionals and other professionals, with views tailored to the many different roles and services. TelluCare integrates with electronic patient records used by customers. In TransCare, Tellu has been working to integrate patient monitoring with the other TelluCare services for remote monitoring and response, to improve the transition processes. These services include smart home sensors, camera surveillance and security alarms with call centres. TransCare patients use the Dialogg app. Dialogg connects to devices via Bluetooth to transmit the measurements taken. They are sent to two places in parallel – to TelluCare where the measurements are stored and can be viewed in the traditional web interface, and to ML Analytics where they are stored and processed.
Karde offers, via the life management assistant Memas, the communication platform between the patient and the caregivers. The Memas version used in the TransCare project is called Memas Rehabilitation. It is intended for people undergoing rehabilitation at home after a hospital stay. It is configured with the necessary information depending on the diagnosis. Memas Rehabilitation has services for calendar, contacts, information about the disease, recommendations for activity and exercise, recommendations about diet, the possibility of submitting wellness reports, as well as a link to the Dialogg app in TelluCare. An editing tool has been developed that supports entering descriptions of diagnoses, activity and diet recommendations in addition to creating questionnaires for wellness reports.
TUC will develop a post-discharge machine learning (ML)-based analysis that analyzes the monitored data on daily activity and vital signs to enable healthcare professionals to detect issues that require proactive intervention.
The analysis uses deep learning to predict heart rate during physical activities such as running, walking, swimming or cycling, for a specific patient. The ML model uses monitored data collected through the Tellu Dialogg application: (i) Fitbit time series data, (ii) daily summary and (iii) data from other sensors or devices integrated into the external monitoring platform (e.g. smart blood pressure monitor, etc.). The model allows for comparison of actual values ??with the personalized predictions (e.g. predictions of heart rate during specific activities).
Patients are currently being recruited. 80 in Norway, 100 in Italy and 30 in Romania. Half of them receive TransCare services. The other half are in the control group who receive services as they have been until now.
The technological solutions will be evaluated during the user testing and modified if need be.
Flere studier viser at vellykket innføring av nye teknologier avhenger av brukeraksept, brukervennlighet og integrasjon i brukerens dagligliv. Vi vil samarbeide tett med pasienter, helsepersonell og pårørende gjennom hele overgangsprosessen, fra utskriving fra sykehuset til pasienten er godt etablert i hjemmet. For å utvikle en enhetlig og tilfredsstillende prosess for alle parter, vil vi ta i bruk metoder fra tjenestedesignfaget.
I Norge skal vi rekruttere 80 eldre pasienter (40 for oppfølging i prosjektet, 40 i en kontrollgruppe). Når pasienten er utskrivningsklar vurderer forvaltning i kommunen hvilke tjenester som blir tildelt.
Pasientene som får oppfølging vil få tildelt tjenester via løsningene:
TelluCare, et system utviklet for avansert hjemmebasert omsorg og overvåking/oppfølging av pasienter, inkluderer trygghetsalarm, kameratilsyn, døralarm og medisineringsstøtte. Plattformen bruker ulike sensorer og medisinsk utstyr koblet til digitale enheter for å samle inn pasientdata, som overføres til helsepersonell for analyse og oppfølging. Utstyret leveres til pasienten av kommunen i samarbeid med behandlingshjelpemidler fra Sørlandet sykehus (SSHF), og tilpasses pasientens sykdomsbilde. Pasientens tilstand måles, analyseres og kategoriseres i henhold til triage-systemet med grønn, gul og rød kategorisering. Ved gul eller rød kategori, vil det bli sendt melding til oppfølgingstjenesten (hjemmetjenesten eller KØH) i Farsund kommune for videre oppfølging.
Memas, som leveres av Karde, er en livsmestringsassistent og vil håndtere humanaspektene i transisjonsprosessen mellom sykehus og hjem. Memas vil utvides med funksjoner for relevant selvrapportering om hvordan pasienten føler seg (avhengig av hvilke diagnoser pasienten har), læring om det som er godt å vite i den aktuelle situasjonen, treningsråd og -instruksjoner fra start til avslutning av prosessen, kostholdsråd, konsultasjonsmulighet med oppfølgingstjenesten i Farsund kommune. og evt. bistand til medisinering.
