Leader: Tiziana Russo Spena (UNINA); Other collaborator(s):
1) Analysis of patients’ needs based on risk-based segmentation. 2) Analysis of patient journey as it is (patients, families, doctors, caregivers), etc. and identify different patient journey mapping. 3) Define how smart technologies can improve patient engagement and journey as well as caregivers’ involvement to sustain personalized prevention. 4) Codify new patient journey risk-based mapping 5) Design the architecture of system of insight and system of engagement to foster personalized prevention in patient journey. 6) Evaluation and measurement of health outcome, i.e. patients’ wellbeing. 7) Propose practices and policies related to personalized prevention for caregivers, professionals and policy-makers
Brief description of the activities and of the intermediate results
Literature review using Kitchenham and PRISMA approach including the following research items: digital technology (digital solution, mobile app, Internet of Thinks, ...), digital health (telemedicine, telerehabilitation, digital medicine,...), and ageing processes (including healthy ageing, ageing management, ageing prevention). On the 2062 references investigated, 1156 were exluded as duplicated, 343 were excluded for eligibility, 256 after screening of title and abstract, leaving 307 articles for full text screening.
After a quality assesment, 259 were removed, leaving 42 articles for the revision.
Main policy, industrial and scientific implications
Building on the guiding principles of connected care and the patient journey, an advanced conceptual model was developed that identifies three main categories through which digital solutions should operate to optimize health care: prevention, personalized care, and health maintenance. These categories do not operate in isolation but intersect synergistically, reflecting and extending the key concepts of the patient journey and connected care. Through this proposed conceptual lens, it is possible to see how integrated digital solutions can transform health care, making it more responsive to individual needs, anticipating health problems before they occur, and maintaining a high level of overall well-being through constant and personalized monitoring.
This approach not only improves the effectiveness of health care but also promotes healthier, independent aging, an aspect of growing importance in a society that sees the average age of the population steadily increasing.
Brief description of the activities and of the intermediate results
The systematic review of emerging smart healthcare technologies has been completed, providing the foundation for subsequent analyses. The review examined telemedicine, remote monitoring, AI-driven diagnostics, and digital therapeutics, assessing their potential to enhance patient engagement, improve caregiver support, and facilitate personalized healthcare interventions. The findings highlight key trends, technological gaps, and opportunities for integration into healthcare pathways.
Main policy, industrial and scientific implications
The results of the review were presented and discussed in two stakeholder meetings, focusing on methodologies for stakeholder engagement in digital healthcare innovation. The discussions explored strategies for integrating digital solutions into patient care, emphasizing their potential for risk-based patient segmentation and personalized prevention.
Brief description of the activities and of the intermediate results
Building on the insights from the systematic review, preliminary qualitative interviews with two patients, two caregivers, and one healthcare professionals were conducted. These interviews aimed to map existing patient journeys by documenting experiences, identifying pain points, and understanding gaps in care coordination. The qualitative data collected provides valuable insights into real-world challenges, informing the next phase of patient journey analysis.
Main policy, industrial and scientific implications
Not applicable
Brief description of the activities and of the intermediate results
A preliminary patient journey mapping framework has been established, categorizing different patient pathways based on their risk profiles, healthcare interactions, and support systems. This framework will serve as a reference for designing targeted interventions, optimizing digital healthcare solutions, and informing policy discussions on personalized prevention strategies.
Main policy, industrial and scientific implications
Not applicable
Brief description of the activities and of the intermediate results
Following the establishment of the preliminary patient journey mapping framework, a qualitative study involving key healthcare system stakeholders was launched to contextualize and refine the initial findings. In-depth interviews and focus groups were conducted with 2 clinicians, 1 care managers, 1 digital solution developers, and 1 health service administrators. The aim was to explore their perspectives on the feasibility of implementing personalized prevention pathways, current gaps in care coordination, and the integration of digital tools into routine workflows
Main policy, industrial and scientific implications
Not applicable
Brief description of the activities and of the intermediate results
During this quarter, the qualitative study launched in the previous phase was further developed through the systematic analysis of data collected from interviews and focus groups with 2 clinicians, 1 care manager, 1 digital health solution developer, and 1 healthcare service administrator.
The stakeholder-informed journey map guided the design of an interview protocol tailored to real-life care contexts. This allowed the research to move from abstract system representations to individual narratives and to build a multi-dimensional patient journey model, aligned with the objectives of risk-based segmentation, by incorporating clinical, social, relational, and digital vulnerabilities relevant to prevention.
The analysis followed a thematic mapping approach, identifying recurring care patterns, critical transitions, and systemic barriers.
Professionals described typical care situations involving older adults with cognitive decline, highlighting:
• The characteristic phases of the patient’s journey (e.g., initial cognitive concerns, diagnostic uncertainty, transitions to home care),
• Barriers and unmet needs emerging along the pathway (e.g., difficulty in early detection, fragmented service access, caregiver overload),
• Points of interaction with the care system where key decisions or disruptions occur (e.g., GP consultations, social service referrals, informal care arrangements).
The resulting model frames the patient journey as a relational and distributed process, embedded in a micro-level care ecosystem shaped by interactions among general practitioners, social workers, informal caregivers, and service coordinators.
Main policy, industrial and scientific implications
This phase underscores the importance of designing care models that reflect the complexity of real-world interactions between patients, caregivers, and professionals. From a policy perspective, it highlights the need for integrated service frameworks that promote continuity of care and stakeholder collaboration. Scientifically, it contributes to advancing stakeholder-centred approaches in care pathway research and supports the development of multidimensional models for personalised intervention design.
Brief description of the activities and of the intermediate results
Brief description of the activities and of the intermediate results Building on the stakeholder-informed mapping conducted in the previous quarter, this phase aimed to explore patient experiences in greater depth. The thematic areas that emerged during the professional interviews—such as care fragmentation, reliance on informal caregivers, social vulnerability, and uneven access to digital resources—served as analytical anchors for designing in-depth interviews aligned with the four dimensions of the risk-based segmentation framework (clinical, relational, social, digital).
Based on this approach, the qualitative research was expanded through in-depth interviews with 10 older adults with early-stage cognitive impairment, recruited from a selected local care setting (currently being formalised). To capture the relational and social contexts surrounding daily care, additional interviews were conducted with 6 formal caregivers and 10 informal caregivers, providing complementary insights into support networks, challenges, and digital readiness.
The insights collected contributed to the identification of distinct vulnerability profiles, such as:
• High clinical complexity with low digital access but strong informal relational support;
• Social isolation combined with solid digital confidence and moderate clinical needs;
• Mild clinical risk accompanied by insufficient relational support and limited digital readiness.
Each profile was linked to differentiated care pathways and tailored digital support strategies, reinforcing the framework’s capacity to guide inclusive, context-sensitive, and prevention-oriented service design.
Main policy, industrial and scientific implications
This phase further emphasises the importance of developing care models that integrate the complexity of real-world experiences of patients and their support networks. From a policy perspective, the identification of differentiated vulnerability profiles points to the need for prevention strategies that combine clinical assessment with relational, social, and digital considerations. This highlights the value of coordinated service frameworks capable of supporting early detection, sustained engagement, and tailored interventions for individuals with emerging cognitive decline.
Brief description of the activities and of the intermediate results
During this phase, the main results of the task were presented and discussed with experts in dedicated sessions aimed at contextualising the findings and assessing their applicability to real-world care settings. These exchanges offered valuable input for framing the proposed typologies of patient journeys and vulnerability profiles within current discussions on personalised prevention. The outcomes of these meetings also contributed to defining key directions for dissemination. In parallel, work began on the preparation of a scientific publication to support knowledge transfer and engage both academic and professional audiences.
Main policy, industrial and scientific implications
The exchange with experts helped to highlight the potential of the proposed framework to inform integrated and multidimensional approaches to prevention. From a policy perspective, the discussion pointed to possible directions for structuring services around patients' needs, taking into account clinical, social, relational, and digital vulnerabilities. In the industrial domain, the findings offer elements to guide the development of tailored digital solutions and care pathways. Scientifically, the initiation of dissemination activities contributes to the advancement of context-sensitive models for personalised prevention and supports their positioning within current debates on care innovation and ageing.
A preliminary patient journey mapping framework has been established