Multimorbidity and integrated care

Digital decision support for integrated care of chronic conditions

HOPE Care / CMX is a digital decision support and communication tool for integrated care of patients with multiple chronic conditions (multimorbidity). The solution is used within the framework of the European research project CAREMATRIX, in collaboration with Region Skåne (Sweden), Vestre Viken Hospital Trust (Norway) and Osakidetza-Basque Health Service (Spain).

HOPE Care / CMX is based on the same platform as HOPE Care / My Health and HOPE WebROP, but is specially configured to support coordinated care for elderly patients with complex needs. The solution connects the various healthcare providers and makes it possible to follow the patient’s entire care process – from home to primary care and specialist care – in a shared digital view.

 

AI-based algorithms and automated care plans

HOPE Care / CMX contains a number of rules and algorithms that are configured in HOPE’s decision robot. These algorithms continuously evaluate the patient’s health data from multiple sources:

  • self-reported records via the HOPE App,
  • measurements from integrated medical devices,
  • structured observations from healthcare professionals, and
  • results from validated assessment tools (e.g. SCORE2 and CHA₂DS₂-VASc).

The collected data is analysed in real time and results in evidence-based recommendations and risk classifications that are presented visually in HOPE Practitioner. The system enables healthcare providers to prioritise patients with the greatest need for intervention and to initiate the right measures at the right time.

Personalised care process and self-monitoring

Patients have access to a personalised care process in the HOPE App, where all activities, measurements and forms are tailored to their diagnosis, risk profile and follow-up plan.

Activities include, for example:

  • daily recording of blood pressure, weight and symptoms,
  • weekly forms that measure quality of life and functional level (e.g. EQ-5D, VAS, CAT),
  • chat and video meetings with healthcare professionals, and
  • notifications reminding patients of new measurements or digital meetings.

The app provides patients with immediate feedback in the form of colour-coded graphs and tables, which strengthens their motivation for self-care and compliance. In this way, HOPE Care / CMX supports sustainable self-management where patients become active participants in their treatment.

Communication and cooperation between healthcare providers

HOPE Care / CMX has been developed to enable collaboration between primary care, hospitals and municipal care. Through HOPE Practitioner, all actors have access to a shared view of the patient’s measurement data, form responses, activities and action plans.

The system supports role-based access control (RBAC) and access-based access control (ABAC) according to the healthcare provider’s organisation, and the documentation complies with the requirements of the Health and Medical Services Act.

Automatic notifications are sent to the relevant healthcare staff when the patient’s values deviate from the expected range or when a new activity requires action. This enables early detection of deterioration and rapid resource allocation to the patients who need the most support.

Scientific basis and international trials

HOPE Care / CMX is being evaluated as part of the CAREMATRIX Phase 3 study, which is being conducted simultaneously in three regions:

  • Region Skåne (Sweden)
  • Vestre Viken Hospital Trust (Norway)
  • Osakidetza-Basque Health Service (Spain)

The study focuses on the usability and functional validation of the solution in everyday clinical practice. The tests involve patients, relatives and healthcare staff and evaluate how digital care plans, warning systems and decision support work in practice.

Real-world evidence from previous use of the HOPE platform shows that the same digital logic has already improved efficiency, documentation quality and patient safety in other care flows – including heart failure, cystic fibrosis, inflammatory bowel disease and neonatal care.

A tool for the future of person-centred care

HOPE Care / CMX provides healthcare providers with a tool that supports the transition to person-centred and proactive care. By combining data from multiple levels of care and allowing patients to actively participate in follow-ups, resources can be directed to the right person at the right time. The solution contributes to:

  • earlier identification of risk profiles,
  • better coordination between healthcare providers,
  • reduced administrative burden, and
  • increased patient participation and continuity.

HOPE Care / CMX is thus a natural continuation of the HOPE platform’s established solutions in digital monitoring and clinical decision support – and represents an important step towards integrated, sustainable and data-driven care for patients with chronic diseases.

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