CKD Integrated Care

CKD is a silent disease that should be early identified by general practicioners (GPs) for an early referral to nephrologists to avoid its progression towards end stage kidney disease. The clinical characteristics of CKD patients have changed in recent years (aging and complexity), resulting in an increased burden of care for the healthcare facilities and the need for a more extensive involvement of families and social services.
In this context, our practice aims to create a new technological system, based on a new “digital” healthcare model, involving cooperation among different territorial care entities. Specifically, our practice aims to prevent CKD in general population, to early identify patients affected by CKD, to increase de-hospitalization of patients with overt CKD starting dialysis, to improve quality of life and to reduce the healthcare costs.
CKD integrated-care (Smart Health 2.0 project)is aplatform with ane-learning environment,with edu-games for the empowermentof the general population (Help-Large) and patients affected by CKD with their caregiver, a business intelligence tool on board (ULYSSES) for the early identification of CKD patients through the analysis of clinical pathology data, a sofa (DIADOM), inspired by home living design and fully equipped with medical devices connected toa telemonitoringsystem (TELCARE) able to create an audio-video connection between patients, nurses and nephrologists.
In addition, Smart Health 2.0 project has trained Care and Case managers, Nurses and Physicians with specific expertise on the use of Ulysses, Help-Large and telemonitoring/teledialysis system, those will be the new professionals required for the creation of virtuous paths between hospital and territory.

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Policy Priorities
Digital tools for citizen empowerment and for person-centred care
Academia, Advocacy organisations patients/users, Advocacy organisations physicians, Day care centres, Home care centres, Housing organisations, Informal caregivers, Large-sized industry (more than 250 employees), Medium-sized industry (50-249 employees), Micro-sized industry (fewer than 10 employees), National public authorities, Nurses, Nursing homes, Private companies, Regional public authorities, Research centres, Small-sized industry (10-49 employees), WHO
Geographical Scope
National level
Total Budget
€1M – €5M
Available upon request
People reached
> 100,000