SciTransfer
CONNECARE · Project

Smart Care System That Keeps Chronic Patients at Home and Out of Hospital

healthPilotedTRL 7
connecare.eu

Imagine a patient with multiple chronic conditions — diabetes, heart problems, lung disease — bouncing between doctors who don't talk to each other. CONNECARE built a connected system that links all their care providers, tracks the patient's activity and health at home, and uses smart algorithms to flag problems before they become emergencies. Think of it like a GPS for healthcare: it maps where each patient is on their health journey, predicts risks, and recommends the best route — keeping people healthier at home instead of ending up in hospital.

By the numbers
11
consortium partners across Europe
6
countries involved (DE, ES, IL, IT, NL, UK)
3
clinical trial regions (Catalonia, Israel, Groningen)
28
total project deliverables produced
5
dimensions in patient risk scoring strategy
3
SMEs in the consortium
The business problem

What needed solving

Healthcare systems across Europe are overwhelmed by chronic patients who need coordinated care from multiple providers — but these providers often work in silos with incompatible systems. The result is reactive, hospital-centred care that is expensive, fragmented, and leads to poor outcomes. There is an urgent need for smart tools that can identify high-risk patients early, coordinate their care across settings, and empower them to manage their own health at home.

The solution

What was built

CONNECARE delivered a complete integrated care system with 28 deliverables, including: a Smart Adaptive Case Management System for care coordination, a Clinical Decision Support System for adaptive clinical pathways, a Recommender System for patient self-management, a Quality of Life Assessment tool, a risk Stratification and Mapping DSS, the DARWIN healthcare platform, and a 3-level patient monitoring system — all tested in clinical trials across 3 European regions.

Audience

Who needs this

Regional health authorities managing chronic disease populationsHospital groups trying to reduce readmission ratesDigital health companies building chronic care platformsHealth insurers looking to lower costs for complex patientsHome care providers expanding into connected care services
Business applications

Who can put this to work

Healthcare IT / Hospital Systems
enterprise
Target: Regional health authorities or hospital groups managing chronic disease populations

If you are a hospital group struggling with readmission rates for chronic patients — this project developed a complete integrated care system with risk stratification, clinical decision support, and 3-level patient monitoring that was tested in clinical trials across 3 European regions (Catalonia, Israel, Groningen). The system connects health and social care providers on one platform and shifts care from reactive hospital visits to preventive home-based management.

Digital Health / Telehealth
mid-size
Target: Telehealth platform providers looking to add chronic care management features

If you are a digital health company looking to expand into chronic care — CONNECARE produced a ready-to-integrate recommender system for patient self-management, a quality-of-life assessment tool, and an adaptive case management engine. These components were designed for interoperability and transfer to other ecosystems, as documented in their final system release covering 28 deliverables.

Health Insurance / Managed Care
enterprise
Target: Health insurers or managed care organizations seeking to reduce costs for high-risk patients

If you are a health insurer dealing with rising costs from complex chronic patients — this project built a 5-dimension patient scoring system (screening, risk stratification, mapping, intervention, surveillance) that identifies high-risk individuals early and routes them into personalized care pathways. Clinical trials with 11 consortium partners across 6 countries validated the approach for reducing unnecessary hospital use.

Frequently asked

Quick answers

What would it cost to implement this system?

The project data does not include specific pricing or licensing costs. CONNECARE was publicly funded research (RIA), so the technology would need to be licensed from consortium partners — primarily FUNDACIO EURECAT (Spain) as coordinator. Implementation costs would depend on integration complexity with existing hospital IT systems.

Can this scale to manage thousands of chronic patients?

The system was designed for population-level chronic care management, combining population-based risk tools with individual patient scoring across 5 dimensions. Clinical trials were conducted in 3 regions (Catalonia, Israel, Groningen) with established healthcare systems, suggesting the architecture supports real-world patient volumes. The DARWIN healthcare platform was specifically built to handle this scale.

Who owns the intellectual property and can we license it?

IP is distributed across the 11 consortium partners from 6 countries. The coordinator FUNDACIO EURECAT (Spain) is the primary contact. With 4 industry partners and 3 SMEs in the consortium, some components may already have commercial licensing paths. Specific IP terms would need to be negotiated with the relevant partners.

Does this comply with healthcare regulations?

The system was tested in clinical trials across 3 European healthcare regions, which implies compliance with local clinical and data protection requirements at the time. However, the project ended in 2019, before some current regulations took effect. Any deployment today would need updated compliance review for GDPR, MDR, and local health data laws.

How long would it take to deploy?

Based on available project data, the consortium went through iterative co-design and refinement cycles over approximately 3.5 years. For a healthcare organization adopting the finished system, deployment time would depend on existing IT infrastructure and interoperability requirements. The final system release documented lessons learned in interoperability and transfer to other ecosystems.

Does this integrate with existing hospital information systems?

Integration was a core design goal. The system offers smart Adaptive Case Management, self-management tools, and 3-level monitoring features described as fully integrated with management systems in place. The final release deliverable specifically covers interoperability models and transfer to other ecosystems.

Consortium

Who built it

The CONNECARE consortium brings together 11 partners from 6 countries with a balanced mix: 4 industry partners (36% industry ratio), 3 universities, 4 research organizations, and 3 SMEs. Led by FUNDACIO EURECAT, a major Spanish technology centre, the consortium spans Germany, Spain, Israel, Italy, Netherlands, and the UK — covering diverse healthcare systems for validation. The presence of 4 industry partners and 3 SMEs alongside academic institutions signals a project designed for real-world adoption, not just academic publication. Clinical trials in Catalonia, Israel, and Groningen were run through partners active in the EIP AHA B3 Action Group, providing built-in channels for European-wide transfer.

How to reach the team

FUNDACIO EURECAT, Spain — contact through SciTransfer for introduction

Order a report on this consortiumSee FUNDACIO EURECAT profile →
Next steps

Talk to the team behind this work.

Want to explore licensing CONNECARE's chronic care platform or specific components like the risk stratification DSS? SciTransfer can connect you directly with the right consortium partner.

Order a report on this topicMore in Health & Biomedical
More in Health & Biomedical
See all Health & Biomedical projects →
Automated Allergy Test Covering All Allergens in One Run, Ready to Ship
AllergyExplorer
Open →
Lab-Sized 3D Cell Microscope Replaces 12-Month Waits at Giant Synchrotron Facilities
LICENT
Open →
Blood Test Platform That Catches Rare Diseases Early Using AI-Powered Diagnostics
METAdiag
Open →