TransCare

Abstract

TransCare is a project funded under the AAL Joint Programme's THCS initiative, targeting one of the most persistent challenges in eldercare: the high rate of hospital readmission among older adults following discharge. Its core goal is to improve transitional care pathways from hospital to home through technology-assisted monitoring and follow-up, while building the clinical evidence and value proposition needed to justify broader adoption across different European healthcare systems. The project enhances and scales an existing remote patient monitoring platform — incorporating machine learning-based post-discharge assessment, personalised coaching, and digital tools for self-management — to support older patients with multimorbidity in the critical weeks following hospitalisation. The platform enables remote interaction between patients, informal caregivers, and health personnel through features such as structured questionnaires, self-treatment planning support, dietary guidance, and chat-based communication, all adapted to the local language, care roles, and regulatory context of each pilot site. Recognising that transitional care is deeply shaped by local healthcare structures, TransCare operates across three countries with meaningfully different systems: Italy, where families and next of kin carry significant responsibility; Norway, where municipalities manage much of the post-hospital care pathway; and Romania, where family networks similarly play a central role. A consortium of six partners — spanning a technical university, clinical end-user institutions, and technology SMEs — brings together expertise in machine learning, eHealth platform development, assistive technologies, and geriatric care. The clinical validation involves 210 patients aged 65 or older, recruited across three pilot sites and followed for a minimum of three months in a controlled intervention vs. control design. The primary outcome is reduction in 30-day hospital readmission rates, alongside broader impact assessment across qualitative and quantitative indicators. The project runs for 36 months from May 2024, with a total budget of approximately €2.16 million.

Research Domains