title: An adaptive case management system to support integrated care services: Lessons learned from the NEXES project.
abstract: BACKGROUND
  Extensive deployment and sustainability of integrated care services (ICS) constitute an unmet need to reduce the burden of chronic conditions. The European Union project NEXES (2008-2013) assessed the deployment of four ICS encompassing the spectrum of severity of chronic patients.
  
  
  OBJECTIVE
  The current study aims to (i) describe the open source Adaptive Case Management (ACM) system (Linkcare®) developed to support the deployment of ICS at the level of healthcare district; (ii) to evaluate its performance; and, (iii) to identify key challenges for regional deployment of ICS.
  
  
  METHODS
  We first defined a conceptual model for ICS management and execution composed of five main stages. We then specified an associated logical model considering the dynamic runtime of ACM. Finally, we implemented the four ICS as a physical model with an ICS editor to allow professionals (case managers) to play active roles in adapting the system to their needs. Instances of ICS were then run in Linkcare®. Four ICS provided a framework for evaluating the system: Wellness and Rehabilitation (W&R) (number of patients enrolled in the study (n)=173); Enhanced Care (EC) in frail chronic patients to prevent hospital admissions, (n=848); Home Hospitalization and Early Discharge (HH/ED) (n=2314); and, Support to remote diagnosis (Support) (n=7793). The method for assessment of telemedicine applications (MAST) was used for iterative evaluation.
  
  
  RESULTS
  Linkcare® supports ACM with shared-care plans across healthcare tiers and offers integration with provider-specific electronic health records. Linkcare® successfully contributed to the deployment of the four ICS: W&R facilitated long-term sustainability of training effects (p<0.01) and active life style (p<0.03); EC showed significant positive outcomes (p<0.05); HH/ED reduced on average 5 in-hospital days per patient with a 30-d re-admission rate of 10%; and, Support, enhanced community-based quality forced spirometry testing (p<0.01). Key challenges for regional deployment of personalized care were identified.
  
  
  CONCLUSIONS
  Linkcare® provided the required functionalities to support integrated care adopting an ACM model, and it showed adaptive potential for its implementation in different health scenarios. The research generated strategies that contributed to face the challenges of the transition toward personalized medicine for chronic patients.
authors: Hospital Clínic, IDIBAPS, CIBERES, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain. Electronic address: iscano@clinic.ub.es.
authors: Isaac
authors: I
authors: Cano
authors: Hospital Clínic, IDIBAPS, CIBERES, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
authors: Albert
authors: A
authors: Alonso
authors: Hospital Clínic, IDIBAPS, CIBERES, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
authors: Carme
authors: C
authors: Hernandez
authors: Hospital Clínic, IDIBAPS, CIBERES, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
authors: Felip
authors: F
authors: Burgos
authors: Hospital Clínic, IDIBAPS, CIBERES, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
authors: Anael
authors: A
authors: Barberan-Garcia
authors: Linkcare Health Services, C/Roger de Llúria 50, Sobreático A, 08009 Barcelona, Spain.
authors: Jim
authors: J
authors: Roldan
authors: Hospital Clínic, IDIBAPS, CIBERES, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
authors: Josep
authors: J
authors: Roca
mesh_terms: D019090:Case Management / Q000458:organization & administration*; D002908:Chronic Disease / Q000628:therapy*; D020000:Decision Support Systems, Clinical / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D057286:Electronic Health Records / Q000458:organization & administration*; D005060:Europe; D006801:Humans; D020407:Internet / Q000458:organization & administration; D008498:Medical Record Linkage / Q000379:methods*; D017146:Models, Organizational; D012984:Software; D012985:Software Design; D014584:User-Computer Interface
keywords: Adaptive case management; Coordinated care; Integrated health care systems; Medical internet of things; Personalized care