Executive Summary

Mission

AdsuM+ is an Integrated Care online and interoperable IT platform for delivering pro-active care to patients with chronic conditions. It relies on pre-existent IT systems (HIS, EHR) to get patients and providers’ data and then designs and delivers care through Integrated Care Pathways (ICPs) for Chronic Patients (Heart Failure, Diabetes, Hypertension, COPD…).

Care is delivered from a multi-disciplinary group including Health Providers (at primary and hospital levels), Community, Social Care and Patients/Relatives/Informal Caregivers.

ICPs are agreed among all stakeholders and care actions are designed using AdsuM+ ICP Engine so every actor has a specific part to accomplish (i.e. Primary Care Doctor asks questions on HF condition and attends triggered alerts, Case Manager Nurses track vital signs, Educational Team delivers educational content and measures patient’s engagement and adherence to it, Social Workers track patient’s dependency and ability to do an independent living, Patient actively participates answering questions and communicates with its multi-disciplinary care team…).

Relevant information on the designed ICPs is shared among the multi-disciplinary team and what is relevant is integrated into Health Systems. AdsuM+ is also fed with relevant data from this HIS to automatically adapt care plans to day-to-day changes (i.e. Hospital admissions automatically adapt care plans scheduled for all stakeholders: social worker visit is re-scheduled, new tasks for Primary Care Nurses are programmed when discharge happens, Specialists at the Hospital review the entire care plan and its level of accomplishment…).

Vision

AdsuM+, already implemented in different usage cases in Spain, Cyprus, Latvia and Croatia, provides realistic and pragmatic solutions for two of the most important challenges Health Systems face nowadays:

  1. How to shift from delivering reactive care (patient needs to tell providers something is not ok) to pro-active care (providers track how patients accomplish their own customized Integrated Care Pathway). This is a critical problem Health Systems need to face to ensure its own long term viability.
  2. How to really deliver Integrated Care: health and social providers need an integrated way to effectively share information, collaborate and avoiding unnecessary use of resources (double visits, non-update of care plans because of missing information, bad leveraging of social resources so sanitary resources are misused…). AdsuM+ offers a tested way to include as many stakeholders as needed in a Patient’s Circle of Care, deciding which pieces of information to share and which pieces to not share.