Telemonitoring programme for chronic patients

Lombardy / Chronic Related Groups - Telemonitor

LOMBARDY  / Telemonitoring programme for chronic patients:   49/60 11/20

Current healthcare practice in EU countries is primarily focused on the acute hospital sector. If modern healthcare systems want to respond to the major illness of the 21st century, however, they need to develop a systematic approach to intervene earlier in the course of chronic diseases. One solution is to provide the most intensive care, in the least expensive setting—nearer to, or in, their home.

Customer's need

To achieve this, we need to monitor vital signs, detect early exacerbation, and provide closed-loop feedback with the patient. This combination will help minimise the effects of disease and reduce complications. The current approach to patient care and disease management is reactive, unplanned and episodic. The overarching strategy should be towards a care system that empowers patients to take more control of their treatment regime.

The solution

Patients participating to the GReG programme are classified according to a risk stratification tool, which identifies the most critical patients within the region. High-risk patients use a telemonitoring service, through which vital signs are monitored daily. Values are checked against thresholds, predefined by their GPs. In case of significant deviations from healthy values, or in case of identification of problematic situations, a Service Centre intervenes by calling the patients, and assessing the situation through a specific triage procedure. The GP is always in the loop. In case of need, the GP can take action (visit the patient, suggest changes in the prescribed therapies, etc.).

Contact information

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Marco Nalin

Program partners