Objectives

C3-Cloud’s objectives are to:

  • • Enable the development of personalised care plans for multi-morbid conditions through systematic and semi-automatic reconciliation of digitally represented clinical guidelines for individual chronic conditions, by a group of collaborating health and social care givers, and with the informed participation of the patients and their informal care givers.
  • • Provide an innovative online platform through which multidisciplinary care team members (MDT) can collaboratively manage (execute, monitor, update) 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 caregivers to the management of their multi-morbid chronic conditions through a Patient Empowerment Platform to alleviate challenges that patients face to adhere to various treatment regimes for each chronic condition.
  • • Provide an Interoperability Middleware addressing that will seamlessly integrate all the interoperable components of the infrastructure in accordance to best-practice and state-of-the-art technologies and standards.
  • Demonstrate the applicability of C3-Cloud integrated care approach by piloting in three European regions (South Warwickshire, Basque Country and Region Jämtland Härjedalen) with 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 supported with ICT in diverse settings.