The project proposes an enabling digital infrastructure able to support the collaboration among diverse actors operating in different settings across the continuum of care, sharing relevant information and implementing new care models for frail and pre-frail older adults.
The solution consists of two core components:
1) the Case Management (CM) module that acts as broker of continuity of care, by supporting enrolment, multidimensional need assessment and care plan personalization;
2) the standard-based interoperability platform that allows the CM to interoperate with the healthcare systems and to integrate as added value solutions: a) EMR for managing psychological and decline cognitive factors; b) telemonitoring and telerehabilitation systems; c) AI-based Natural Language Understanding engine, for the automatic detection of the emotional status; d) BI module and cybersecurity methodologies. The solution is modular, scalable and affordable for implementing sustainable business models.