C3-Cloud

C3-Cloud has the following objectives:

• Enable the development of personalised care plans for multi-morbid conditions through systematic and semi-automatic reconciliation of digitally represented clinical guidelines
• Provide an innovative online platform through which multidisciplinary care team members (MDT) can collaboratively manage the integrated personalised care plans for patients with multi-morbid conditions
• Provide Clinical Decision Support Modules to support personalised care plan development and execution by clinical guideline reconciliation, risk stratification, poly-pharmacy management and goal setting and monitoring
• Ensure active participation of patients and their informal care givers to the management of their multi-morbid chronic conditions through a Patient Empowerment Platform
• Provide an Interoperability Middleware addressing technical, semantic and privacy/security interoperability challenges to seamlessly integrate with the existing health care, social care and home/community care information systems
• Demonstrate the applicability of C3-Cloud integrated care approach and supporting set of innovative ICT components in varying clinical, technological and organisational settings by piloting in three European regions (South Warwickshire, Basque Country and Region Jämtland Härjedalen) with quite different health and social care systems and ICT landscapes
• Analyse the trajectories of C3-Cloud participants and their data to strengthen the evidence base in caring for patients with multiple conditions and to inform future development of more streamlined and optimised multi-morbidity care pathways
• Develop, experiment and refine new adaptive models of integrated care and organisational change management guidelines for achieving the design and implementation of integrated care
• Develop and validate an innovative large-scale impact modelling tool for industrial exploitation and large scale roll out

In total in 3 pilot sites, 150 patients for intense evaluation in exploratory trial (layer 3), 600/600 patients for resource monitoring to support large-scale impact assessment (layer 4) and 62 MDT members will be involved in pilot operation and evaluation activities.

A growing share of the population in OECD countries is age 65 and over: 15% in 2010, and expected to reach 22% by 2030. Older age is associated with an increased accumulation of multiple chronic conditions: multi-morbidity, including a growing number of functional and cognitive impairments. More than half of all older people have at least three chronic conditions, and a significant proportion has five or more. Multi-morbidity creates diverse and sometimes contradictory needs which challenge patients and the delivery of health services, and yet there is a continuously growing demand for health care services to handle multiple chronic conditions, and for social care services to enable such patients perform everyday activities, supported by informal carer or home / community care services.

Unfortunately, current European medical models (e.g. as directed by clinical guidelines) focus primarily on short and medium term interventions on the basis of single conditions, failing to integrate care planning well across providers and often overlooking the interconnected basis of chronic diseases. Managing multi-morbidity, through the current treatment methods, results in specialty silos and fragmented care, involving multiple health and social care providers who are not effectively communicating and sharing information. Hence, the over-arching societal challenge that motivates C3-Cloud is: How can we effectively care for and support elderly patients with multi-morbidity needs by benefiting from advanced ICT solutions?

As the initiator of the C3-Cloud project and a core R&D partner, SRDC roles can be summarized as follows:

• Leading the gathering and analysis of technical requirements of the C3-Cloud Architecture
• Contributing to the conceptual design of the C3-Cloud Architecture
• Implementation of the C3-Cloud Personalised Care Plan Development Platform
• Contributing to the development of the Responsive Multi-Channel Patient Empowerment Platform, Technical Interoperability Platform, and the Semantic Interoperability Platform
• Providing open source privacy and security mechanisms for the overall C3-Cloud Architecture
• Leading the integration of all C3-Cloud components to achieve the Coordinated Care and Cure Delivery Platform
• Contributing to the design and deployment of the C3-Cloud pilot application
• As an industry representative, pursuing commercial exploitation of C3-Cloud results
• Dissemination of C3-Cloud achievements through scientific & technical publications and other events