EASYDOM

The ICT based integrated care of chronic multimorbid patients at their home: the EASYDOM trial

Regione Campania

Università degli Studi Federico II di Napoli

Chronic multimorbid elderly patients represent an high risk population for hospital readmission. Available guidelines suggest that implementing strategies of dietary and behavioral changes as well as pharmacological treatment ameliorate the clinical outcomes. Implementing this approach in the real word is limited by the fragmented delivery of care, which is often offered in sylos. ICT provides an unique opportunity to improve the interaction between hospital and territory, allowing the interchange of information that can be used for a coordinated deliver of home care, and ameliorate the management of chronic conditions. Several good practices have been tested and validated, showing that indeed, strategies based on the ICT implementation, that use devices enhancing pharmacological adherence, physical exercise and therapy, can ameliorate the clinical outcomes of patients and reduce the risk of hospital readmission parameters while providing services where patients live.

The main hypothesis is that an ICT supported, integrated health approach at the home of outpatient, over 65yrs high risk population affected by chronic multimorbid conditions ameliorates clinical outcomes.

The aims of this proposal are:

• to identify the determinants of hard events in this population,
• to identify the optimal intervention under the pharmacological, nutritional and physical activity needs
• to test in a clinical trial the effectiveness of a ICT supported integrated care intervention to ameliorate clinical outcomes

This project will provide several results that will impact overall health outcomes of multimorbid patients. First of all, the definition of integrated care pathway that include pharmacological as well as physical activity and nutrional needs that can be provided with the support of ICT at the home place of patients. Indeed, this first outcome is most needed for the lack of specific guidelines for the home care of the multimorbid patient.

A second outcome will be the educational and training tools for professionals, patients and caregivers to be used for the training of such figures when prescribing and delivering integrated home care.

A final outcome will be the result of a trial during where the effectiveness of the ICT supported integrated care for multimorbid patients will be tested for hard and intermediate endpoints.

Reference facilities

Federico II University of Naples