Technological and Managerial Innovation for the Protection of Frail Patients and Continuity of Care for the Elderly
The aging population—also resulting from the effective treatment of acute, high-mortality conditions—has led to an increased demand for care for elderly individuals with complex health needs. These patients often present with coexisting conditions such as heart failure, renal insufficiency, and diabetes, within a broader context of frailty. They are at high risk of frequent hospitalizations due to the worsening of chronic diseases. Current guidelines recommend remote home monitoring as an essential tool to reduce the social and economic burden related to these patients and to improve their quality of life.
The INTEGRA project successfully developed an IT platform designed to allow the immediate online sharing of current clinical data (blood pressure, electrocardiogram, respiratory activity, body weight, etc.) among all professionals involved in managing frail, elderly, and multi-morbid patients, with the goal of meeting the patient’s healthcare needs.
Specifically, the project led to the development of:
- A home and mobile internet communication infrastructure capable of receiving signals via Bluetooth from sensors that record vital parameters (blood pressure, oxygen saturation, ECG, body weight, etc.);
- Protocols for signal management and analysis;
- An electronic medical record with associated protocols for exporting atomic data from the digital platform.
Partner H&S focused on collecting measurements from the patient’s devices and on creating the data center and web platform for remote data management. Partner DSP was responsible for developing the IT system that collects data from the H&S platform and integrates it into the patient’s dedicated electronic medical record.
The MultiMedica Foundation ETS was tasked with developing the ideal clinical pathway for complex patients, in accordance with the guidelines established by the Lombardy Region. The management platform was validated in two key contexts for chronic disease management: a highly specialized clinical facility (MultiMedica Foundation ETS) and a network of General Practitioners.
Remote monitoring and the shared electronic medical record have helped ensure a high quality of life for vulnerable individuals, by enabling systematic monitoring of the patient’s clinical condition and coordinated home-based therapy management among all involved healthcare professionals.
The INTEGRA product may help reduce both the frequency of hospital admissions and the length of hospital stays, in line with the care models promoted by the Lombardy Region. INTEGRA also represents a scalable solution that can be applied in both national and international settings.
