INCA Solution: A Comprehensive and Sustainable Digital Approach for Proactive , Personalized, and Coordinated Care of Multimobidity Patients in Europe

Background: The management of care for patients with multimorbidity is complex. Care systems in Europe are currently fragmented. The European Commission supported the "Carematrix Project," a Horizon 2020 innovation project, to design a digital platform to enhance integrated care for multimorbid patients in Europe. According to the criteria established by the Carematrix project, the "INCA Solution" was developed. The aim of this document is to report the functionalities that “INCA Solution” offers for the care of multimorbidity patients.

Approach: The study was conducted in collaboration with five partners from two EU countries: DOOLE Health; the Fight Infections Foundation; the Germans Trias i Pujol Research Institute (IGTP); the Faculty of Health Sciences at the Open University of Catalonia (UOC); and the Norwegian Centre for E-Health Research, both WHO members and specialising in eHealth Ecosystem Research and Best Practices in eHealth. The INCA Consortium designed (under the philosophy of five interrelated building blocks) the "INCA platform." Study Setting: The INCA solution has been tested as an innovative platform of a health care for the management of multimorbidity patients in a focus group with patients, informal carers, and health care professionals and will be validated in 3 European site regions during Phase III of Carematrix: Basque Country, Spain; Region Skåne in Sweden; and Vestre Viken in Norway (ongoing).

Results: The INCA solution incorporates various functionalities to support the care of people living with multimorbidity. For the early diagnosis of PMM BB-1 INCA Solution has introduced a systematic process for identifying and selecting people at risk or with multimorbidity. Tools like "INCA Express" and "INCA Complex" are used for rapid multidimensional and holistic assessments. The platform includes surveys, scores, and interventions that are automatically displayed in the patient's electronic health record (EHR). BB-2 INCA platform enables sharing information on patient appointments, consultations, tests, and support from the social care system. It supports the development and follow-up of individual care plans through shared assessment and communication tools. The system allows interoperability between data and information systems from different care providers, including social care. BB-3 INCA solution offers a communication module for interdisciplinary communication with health professionals, enabling inter-consultations, sharing information, and collaborating on patient care. The app also incorporates software for therapeutic conciliation, drug interaction assessment, and adherence control. BB-4 INCA solution offers person-centred care, encouraging social activities to improve physical and mental health. It integrates health portfolios from public and private institutions, providing access to health information. Intelligent reminders and alerts help stay on top of appointments and tasks. BB-5 INCA solution supports personalised health goal setting, education, and information resources. It integrates with the community, addresses burnout syndrome, and encourages patients to achieve goals.

Implications: The INCA solution represents a significant advancement in multimorbidity management by addressing current technological limitations and enhancing patient care. It offers a fully integrated, patient-centred approach, leveraging advanced digital tools and AI technologies for proactive, personalised, and coordinated care. This integration ensures comprehensive care for patients with multimorbidity, addressing both medical and social needs.