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Personalised Connected Care for Complex Chronic Patients

Total Cost €


EC-Contrib. €






 CONNECARE project word cloud

Explore the words cloud of the CONNECARE project. It provides you a very rough idea of what is the project "CONNECARE" about.

stratification    trials    active    organisational    huge    co    transferability    reactive    surveillance    efficiency    smart    recommendations    health    prediction    regions    members    clinical    screening    consisting    strategy    deploy    social    quality    self    population    moving    israel    medicine    model    transfer    institutional    b3    improvements    groningen    iterative    scoring    refinement    settings    leverages    combining    preventive    services    connecare    adaptive    interoperable    mapping    foundations    whilst    patients    them    light    home    monitoring    ambition    contains    empowering    technological    chronic    eip    adoption    stakeholders    assets    decision    personalised    centred    monitor    healthcare    guaranteed    delivering    save    patient    underpinning    4p    care    outcomes    catalonia    dimensions    status    place    shift    paradigm    group    action    substantial    tools    life    sums    ing    dimension    intervention    risk    progressive    aha   

Project "CONNECARE" data sheet

The following table provides information about the project.


Organization address
postcode: 8290

contact info
title: n.a.
name: n.a.
surname: n.a.
function: n.a.
email: n.a.
telephone: n.a.
fax: n.a.

 Coordinator Country Spain [ES]
 Project website
 Total cost 4˙964˙188 €
 EC max contribution 4˙964˙188 € (100%)
 Programme 1. H2020-EU.3.1.6. (Health care provision and integrated care)
 Code Call H2020-PHC-2015-single-stage
 Funding Scheme RIA
 Starting year 2016
 Duration (year-month-day) from 2016-04-01   to  2019-12-31


Take a look of project's partnership.

# participants  country  role  EC contrib. [€] 
3    EWAVE LTD IL (GLIL-YAM) participant 580˙000.00
4    ASSUTA MEDICAL CENTERS LTD IL (TEL AVIV) participant 558˙750.00
10    IP HEALTH SOLUTIONS BV NL (GRONINGEN) participant 133˙775.00


 Project objective

The ambition of the CONNECARE consortium is to co-design, develop, deploy, and evaluate a novel smart, adaptive integrated care system for chronic care management. This will save European healthcare organisations huge sums whilst improving patient outcomes. The consortium contains all the necessary partners to ensure success. Based on the concept of 4P medicine, CONNECARE will provide decision support for the adaptive management of personalised clinical pathways and will deliver tools to monitor patients’ activities and status, thus empowering them and providing them with recommendations to self-manage their condition, resulting in substantial improvements in their quality of life. The three dimensions underpinning the required proposed paradigm shift are: 1. Organisational: making health and social care systems interoperable, promoting collaboration among care settings, and moving from institutional reactive care to a home-based preventive model. 2. Care and social services: addressing health risk prediction by combining already operational population-based tools with a patient-based five-dimension scoring strategy consisting of i) screening, ii) risk stratification, iii) mapping, iv) intervention, and v) surveillance. 3. Technological: delivering a CONNECARE system which leverages existing assets from partners to offer smart Adaptive Case Management, self-management and 3-level monitoring features, fully integrated with management systems in place. An iterative patient-centred co-design process will ensure a progressive refinement of model and tools, providing foundations for adoption and transferability. In addition, clinical trials will be held in three leading-light regions in integrated care uptake –Catalonia, Israel, and Groningen – to evidence improvements in outcomes and efficiency. Consortium members are active in the EIP AHA B3 Action Group; transfer of results to relevant stakeholders across Europe, beyond the stakeholders in CONNECARE, is guaranteed.


List of deliverables.
Final CONNECARE video Websites, patent fillings, videos etc. 2020-04-24 23:35:53
Advanced monitoring tools Documents, reports 2020-04-24 23:33:19
Recommendations of final services and proposals for scale-up integrated care Documents, reports 2020-04-24 23:35:19
Results from CaseStudy1 Documents, reports 2020-04-24 23:34:34
Results from CaseStudy2 Documents, reports 2020-04-24 23:34:49
Final release of the generic CONNECARE system Demonstrators, pilots, prototypes 2020-04-24 23:34:20
Recommender System for self-management Demonstrators, pilots, prototypes 2020-04-24 23:34:04
Final dissemination and communication Plan Documents, reports 2020-04-24 23:35:35
Final Smart Adaptive Case Management System Demonstrators, pilots, prototypes 2020-04-24 23:33:03
CONNECARE Newsletter nº3 Websites, patent fillings, videos etc. 2020-04-24 23:36:15
QoL Assessment System Demonstrators, pilots, prototypes 2020-04-24 23:33:49
Assistive monitoring tools Documents, reports 2020-04-24 23:33:34
Stratification and mapping DSS Demonstrators, pilots, prototypes 2020-04-24 23:32:34
Results from CaseStudy3 Documents, reports 2020-04-24 23:35:04
Self-Adaptive Clinical Pathways CDSS Demonstrators, pilots, prototypes 2020-04-24 23:32:48
First CONNECARE video Websites, patent fillings, videos etc. 2019-05-30 14:12:57
Preliminary dissemination and communication Plan Documents, reports 2019-05-30 14:13:01
Patient-based Health Risk Assessment and Stratification Documents, reports 2019-05-30 14:12:52
CONNECARE Newsletter nº1 Websites, patent fillings, videos etc. 2019-05-30 14:12:54
Project factsheet Websites, patent fillings, videos etc. 2019-05-30 14:12:59
Case studies description and the associated co-design process Documents, reports 2019-05-30 14:13:00
Carry out stakeholder analysis as part of a meeting involving all partners Documents, reports 2019-05-30 14:12:59
Adaptive Case Management Design Documents, reports 2019-05-30 14:12:56
External stakeholder-facing website to assist dissemination and communication Websites, patent fillings, videos etc. 2019-05-30 14:12:55
Basic monitoring tools Documents, reports 2019-05-20 18:44:15
Study Release feasibility for the three clinical studies Documents, reports 2019-05-20 18:44:15
CONNECARE Newsletter nº2 Websites, patent fillings, videos etc. 2019-05-20 18:44:15
DARWIN platform for healthcare Demonstrators, pilots, prototypes 2019-05-20 18:44:14

Take a look to the deliverables list in detail:  detailed list of CONNECARE deliverables.


year authors and title journal last update
List of publications.
2017 Eloisa Vargiu, Juan Manuel Fernàndez, Felip Miralles, Isaac Cano, Elena Gimeno-Santos, Carme Hernandez, Gerard Torres, Jordi Colomina, Jordi De Batlle, Rachelle Kaye, Bella Azaria, Shauli Nakar, M.H. Lahr, Esther Metting, Margot Jager, Hille Meetsma, Stefano Mariani, Marco Mamei, Franco Zambonelli, Felix Michel, Florian Matthes, Jo Goulden, John Eaglesham, Charles Lowe
Integrated Care for Complex Chronic Patients
published pages: 302, ISSN: 1568-4156, DOI: 10.5334/ijic.3619
International Journal of Integrated Care 17/5 2020-01-30
2018 Margot Jager, Maarten M.H. Lahr, Sophie L.W. Spoorenberg, Erik Buskens, Klaske Wynia
Improving self-management of health through an eHealth application: an action-based study among older adults living in the community
published pages: 113, ISSN: 1568-4156, DOI: 10.5334/ijic.s2113
International Journal of Integrated Care 18/s2 2020-01-30
2019 Isaac Cano, Anael Barberan-Garcia, Santiago Iriso, Oscar Solans, Felip Miralles, Josep Roca, Graciela Martínez-Pallí
Implementation of digital health tools for scalability of a prehabilitation service
published pages: 195, ISSN: 1568-4156, DOI: 10.5334/ijic.s3195
International Journal of Integrated Care 19/4 2020-01-30
2017 Eloisa Vargiu
From Healthy to Happy Ageing: the Power of Self-Management
published pages: , ISSN: , DOI:
Third Italian Workshop on Artificial Intelligence for Ambient Assisted Living 2017 co-located with 16th International Conference of the Italian Association for Artificial Intelligence (AI*IA 2017). Bari, Italy, November 16th and 17th, 2017. CEUR proceedings Vol-2061, pp. 1-3. 2020-01-30
2018 Eloisa Vargiu, Juan Manuel Fernández, Felip Miralles
Patient empowerment in connecare
published pages: 258, ISSN: 1568-4156, DOI: 10.5334/ijic.s2258
International Journal of Integrated Care 18/s2 2020-01-30
2018 Erik Baltaxe, Anael Barberan-Garcia, Felip Burgos, Carmen Hernandez, Carmen Herranz, Akos Tenyi, Josep Roca, Isaac Cano
Impact of promotion of physical activity supported by mobile technology on behavioral changes
published pages: PA2055, ISSN: , DOI: 10.1183/13993003.congress-2018.pa2055
Rehabilitation and Chronic Care 2020-01-30
2018 A. Hernandez-Mendez, F. Michel, F. Matthes
A Practice-Proven Reference Architecture for Model-Based Collaborative Information Systems
published pages: , ISSN: 1866-3621, DOI: 10.18417/
Enterprise Modelling and Information Systems Architectures – International Journal of Conceptual Modeling 2020-01-30
2018 Anael Barberan-Garcia, Elena Gimeno-Santos, Isabel Blanco, Isaac Cano, Graciela Martínez-Pallí, Felip Burgos, Felip Miralles, Miquel Coca, Serafín Murillo, María Sanz, Alexander Steblin, Marta Ubré, Jaume Benavent, Josep Vidal, Marta Sitges, Josep Roca
Protocol for regional implementation of collaborative self-management services to promote physical activity
published pages: , ISSN: 1472-6963, DOI: 10.1186/s12913-018-3363-8
BMC Health Services Research 18/1 2020-01-30
2019 E. Baltaxe, C. Embid, E. Aumatell, M. Martínez, A. Barberan-Garcia, J. Kelly, J. Eaglesham, C. Herranz, E. Vargiu, J.M. Montserrat, J. Roca, I. Cano
An Integrated Care Intervention Supported by a Mobile Health Tool in Patients Using Noninvasive Ventilation at Home: Randomized Controlled Trial
published pages: , ISSN: 1438-8871, DOI:
Journal of Medical Internet Research 2020-01-30
2018 E. Vargiu, J.M. Fernández, M. Gonzales-Gonzales, J.M. Morales-Garzón, K. Prunera-Moreda, F. Miralles
Self-Management of Complex Chronic Patients: Needs and A Proposal
published pages: , ISSN: , DOI:
Fourth Italian Workshop on Artificial Intelligence for Ambient Assisted Living 2018 (AI* 2020-01-30
2018 Ákos Tényi, Isaac Cano, Francesco Marabita, Narsis Kiani, Susana G. Kalko, Esther Barreiro, Pedro de Atauri, Marta Cascante, David Gomez-Cabrero, Josep Roca
Network modules uncover mechanisms of skeletal muscle dysfunction in COPD patients
published pages: , ISSN: 1479-5876, DOI: 10.1186/s12967-018-1405-y
Journal of Translational Medicine 16/1 2020-01-30
2018 Emili Vela, Ákos Tényi, Isaac Cano, David Monterde, Montserrat Cleries, Anna Garcia-Altes, Carme Hernandez, Joan Escarrabill, Josep Roca
Population-based analysis of patients with COPD in Catalonia: a cohort study with implications for clinical management
published pages: e017283, ISSN: 2044-6055, DOI: 10.1136/bmjopen-2017-017283
BMJ Open 8/3 2020-01-30
2017 1. J.M. Fernandez, M. Mamei, S. Mariani, F. Miralles, A. Steblin, E. Vargiu, F. Zambonelli
Towards Argumentation-based Recommendations for Personalised Patient Empowerment
published pages: , ISSN: , DOI:
2018 Esther Metting
Opinions of asthma/COPD patients and elderly about the Connecare selfmanagement application
published pages: , ISSN: , DOI:
Primary care respiratory conference 2020-01-30
2018 Ákos Tényi, Emili Vela, Isaac Cano, Montserrat Cleries, David Monterde, David Gomez-Cabrero, Josep Roca
Risk and temporal order of disease diagnosis of comorbidities in patients with COPD: a population health perspective
published pages: e000302, ISSN: 2052-4439, DOI: 10.1136/bmjresp-2018-000302
BMJ Open Respiratory Research 5/1 2020-01-30
2018 G. Martinez-Palli, A. Barberan A.
CONNECARE: A Catalan Clinical Controled Trial’case study on the pre-habilitation before major abdominal surgery
published pages: , ISSN: , DOI:
2018 Pre-habilitation World Conference 2020-01-30
2019 J. de Batlle, E. Vargiu, G. Torres, M. Massip, F. Michel, F. Matthes, F. Miralles, F. Barbé
Implementation of an Integrated Care Platform for the Management of Complex Chronic Patients in Lleida, Spain
published pages: A6246-A6246, ISSN: , DOI: 10.1164/ajrccm-conference.2019.199.1_meetingabstracts.a6246
2019 Erik Baltaxe, Isaac Cano, Carmen Herranz, Anael Barberan-Garcia, Carme Hernandez, Albert Alonso, María José Arguis, Cristina Bescos, Felip Burgos, Montserrat Cleries, Joan Carles Contel, Jordi de Batlle, Kamrul Islam, Rachelle Kaye, Maarten Lahr, Graciela Martinez-Palli, Felip Miralles, Montserrat Moharra, David Monterde, Jordi Piera, José Ríos, Nuria Rodriguez, Reut Ron, Maureen Rutten-van M
Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols
published pages: , ISSN: 1472-6963, DOI: 10.1186/s12913-019-4174-2
BMC Health Services Research 19/1 2020-01-29
2019 Eloisa Vargiu, Juan Manuel Fernández, Mauricio Gonzales-Gonzales, Juan Manuel Morales-Garzón, Kitiara Prunera-Moreda, Felip Miralles
A self-management system for complex chronic patients
published pages: 101, ISSN: 1568-4156, DOI: 10.5334/ijic.s3101
International Journal of Integrated Care 19/4 2020-01-29
2019 A. Barberan-Garcia, M. Ubre, N. Pascual-Argente, R. Risco, J. Faner, J. Balust, A.M. Lacy, J. Puig-Junoy, J. Roca, G. Martinez-Palli
Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial
published pages: 450-456, ISSN: 0007-0912, DOI: 10.1016/j.bja.2019.05.032
British Journal of Anaesthesia 123/4 2020-01-29
2019 Stefano Mariani
Coordination in Socio-technical Systems: Where are we now? Where do we go next?
published pages: 102317, ISSN: 0167-6423, DOI: 10.1016/j.scico.2019.102317
Science of Computer Programming 184 2020-01-29
2019 Eloisa Vargiu, Gerard Torres, Mireia Masip, Juan Manuel Fernández, Felix Michel, Florian Matthes, Felip Miralles
Connected care for complex chronic patients in Lleida
published pages: 102, ISSN: 1568-4156, DOI: 10.5334/ijic.s3102
International Journal of Integrated Care 19/4 2020-01-29
2019 Stefano Mariani, Eloisa Vargiu, Marco Mamei, Franco Zambonelli, Felip Miralles
Deliver intelligence to integrate care: the Connecare way
published pages: 176, ISSN: 1568-4156, DOI: 10.5334/ijic.s3176
International Journal of Integrated Care 19/4 2020-01-29
2017 Isaac Cano, Ivan Dueñas-Espín, Carme Hernandez, Jordi de Batlle, Jaume Benavent, Juan Carlos Contel, Erik Baltaxe, Joan Escarrabill, Juan Manuel Fernández, Judith Garcia-Aymerich, Miquel Àngel Mas, Felip Miralles, Montserrat Moharra, Jordi Piera, Tomas Salas, Sebastià Santaeugènia, Nestor Soler, Gerard Torres, Eloisa Vargiu, Emili Vela, Josep Roca
Protocol for regional implementation of community-based collaborative management of complex chronic patients
published pages: , ISSN: 2055-1010, DOI: 10.1038/s41533-017-0043-9
npj Primary Care Respiratory Medicine 27/1 2019-06-18
2017 Isaac Cano, Akos Tenyi, Emili Vela, Felip Miralles, Josep Roca
Perspectives on Big Data applications of health information
published pages: 36-42, ISSN: 2452-3100, DOI: 10.1016/j.coisb.2017.04.012
Current Opinion in Systems Biology 3 2019-06-18
2017 Marco Mamei, Franco Zamborelli
Novel Opportunities for Tuple-based Coordination: XPath, the Blockchain, and Stream Processing
published pages: , ISSN: , DOI:
2017 Anael Barberan-Garcia, Marta Ubré, Josep Roca, Antonio M. Lacy, Felip Burgos, Raquel Risco, Dulce Momblán, Jaume Balust, Isabel Blanco, Graciela Martínez-Pallí
Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery
published pages: 1, ISSN: 0003-4932, DOI: 10.1097/SLA.0000000000002293
Annals of Surgery 2019-06-18
2016 Xavier Rafael-Palou, Carme Zambrana, Stefan Dauwalder, Enrique de la Vega, Eloisa Vargiu, Felip Miralles
Third Generation Teleassistance: Intelligent Monitoring Makes the Difference
published pages: , ISSN: , DOI:
2nd Workshop on Artificial Intelligence and Internet of Things @ ECAI2016 2019-06-18
2016 Eloisa Vargiu,Felip Miralles, Juan Manuel Fernández, Xavier Rafael-Palou, Carme Hernandez, Elena Gimeno-Santos, Graciela Martinez-Palli, Isaac Cano, Jordi de Batlle, Gerard Torres, Ferran Barbé5, Bella Azaria, Rachelle Kaye, Ayala Doron, Shauli Nakar, Janwillem WH Kocks, Maarten M.H. Lahr, Erik Busken, Klaske Wynia, Hille Meetsma, Vincet Weijers, Marco Mamei, Stefano Mariani, Franco Zambonelli, Florian Matthes, Felix Michel, John Eaglesham, Jo Goulden, Charles Lowe
Personalized Connected Care for Complex Chronic patients
published pages: , ISSN: , DOI:
eHEalth Research 2016 2019-06-18
2018 Xavier Rafael-Palou, Cecilia Turino, Alexander Steblin, Manuel Sánchez-de-la-Torre, Ferran Barbé, Eloisa Vargiu
Comparative analysis of predictive methods for early assessment of compliance with continuous positive airway pressure therapy
published pages: , ISSN: 1472-6947, DOI: 10.1186/s12911-018-0657-z
BMC Medical Informatics and Decision Making 18/1 2019-05-20
2018 Carme Hernández, Jesus Aibar, Nuria Seijas, Imma Puig, Albert Alonso, Judith Garcia-Aymerich, Josep Roca
Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: A Ten Years Pragmatic Assessment
published pages: 12, ISSN: 1568-4156, DOI: 10.5334/ijic.3431
International Journal of Integrated Care 18/0 2019-05-20
2018 José Ignacio Aznar-Baranda, Isabella Notarangelo, Eloisa Vargiu, John Dinsmore, Cristian Barrue
Enhancing the value of care to people: how innovations meet end-users’ needs in integrated care contexts
published pages: 21, ISSN: 1568-4156, DOI: 10.5334/ijic.s2021
International Journal of Integrated Care 18/s2 2019-05-20

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