Intelligent Remote Care

Care closer to home

Several general practices in the Northern Netherlands will soon start with Intelligent Remote Care: an implementation study into digital support for people with an increased cardiovascular risk.

In this project, Ancora Health, UMCG, Leiden University Medical Center, Valtes Care and primary care partners are working together on a new way of delivering care. The approach combines remote monitoring, self-management and lifestyle support in one digitally supported care pathway.

The project builds on earlier experience with remote care and digital support in cardiovascular care, including initiatives such as STEVIT Box and Hart voor Verbinden. These projects explored how smart monitoring, patient insight and digitally supported follow-up can contribute to care closer to home.

The next step is implementation in daily practice: how can this form of care be embedded effectively in general practice, what conditions are needed, and what is required to enable broader scaling?

Remote care means that patients do not always need to visit the general practice or hospital for follow-up or guidance. With the help of an app and simple home measurements, patients can monitor their health and share information with their care team.

Within Intelligent Remote Care, patients use the Care@Home platform. Depending on the care pathway, they may measure their blood pressure, weight and physical activity at home.

But Care@Home goes beyond measurement alone. The platform also supports patients in understanding their measurements and connecting them to daily habits, such as physical activity, nutrition, sleep and stress. This means remote care is not only a way to collect data, but also a way to support self-management and lifestyle change.

For healthcare professionals, this information can help maintain better insight into changes between consultations. This allows them to tailor guidance more closely to the patient’s personal situation and identify earlier when additional support or treatment adjustment may be needed.

This approach brings cardiovascular care closer to the patient’s daily life. Instead of separate measurement moments or fragmented contact points, it creates a more continuous care process in which patients and healthcare professionals gain better insight into health, behaviour and risk.

For patients, this means:

• more insight into their own health;
• more support for self-management;
• practical guidance on lifestyle and daily habits;
• fewer unnecessary physical visits to the practice;
• care that better fits their everyday life.

For healthcare professionals, this means:

• more relevant information between consultations;
• better insight into changes in risk and behaviour;
• support for proactive follow-up;
• more opportunities to tailor guidance to what someone needs;
• insight into how digital care fits within existing workflows.

Many forms of remote monitoring focus mainly on collecting measurements. Care@Home combines monitoring with guidance, insight and lifestyle support.

Patients are not only asked to measure their blood pressure, weight or activity. They are also supported in understanding this information and translating it into daily choices. This creates a care pathway that is more continuous, practical and prevention-oriented.

That is why the implementation study does not only look at technology, but at the full picture: how digital support, behaviour, lifestyle and care processes come together in practice.

Earlier applications of remote care, such as STEVIT Box and Hart voor Verbinden, show that digital support has the potential to organise cardiovascular care differently. This includes better insight for patients, improved follow-up between consultations and opportunities to optimise treatment more quickly.

Intelligent Remote Care builds on this experience. The focus is now on how this approach can be sustainably embedded in primary care and what lessons are needed for broader implementation and scaling. Studying implementation and scaling

The study compares regular care with a care model in which remote monitoring, self-management and lifestyle support are delivered through Care@Home. In addition to assessing comparable outcomes, the emphasis is on implementation.

Key questions include:

• How does Care@Home fit within existing workflows in general practice?
• What support do patients and healthcare professionals need?
• Which technical, organisational and practical conditions are important?
• Which factors support or hinder further scaling?
• How can remote care become part of everyday cardiovascular risk management?

The outcomes of the study will contribute to a practical roadmap for broader implementation of digital remote care in primary care.

This project is carried out in collaboration with partners from healthcare, research and digital health, including Ancora Health, UMCG, Leiden University Medical Center, Valtes Care and primary care partners.

LUMC contributes expertise in cardiology, eHealth, remote monitoring and primary care research, with involvement from Prof. dr. Douwe Atsma and Dr. Tobias Bonten. From UMCG, Dr. Esther Metting and Prof. dr. Marco Blanker are involved.

Together, the partners bring expertise in cardiovascular care, primary care research, eHealth, remote monitoring, lifestyle support, patient-facing technology and implementation in routine care.

Intelligent Remote Care contributes to the next step in digitally supported cardiovascular care. Building on earlier experience with remote monitoring and connected care, this study focuses on what is needed to embed Care@Home sustainably in routine primary care.

The project helps develop a practical roadmap for broader implementation and scaling. This includes patient support, healthcare professional workflows, technical requirements, collaboration between partners and the organisational conditions needed to make remote care, self-management and lifestyle support part of everyday cardiovascular risk management.

General practices that are interested in participating or would like to learn more about Intelligent Remote Care can contact Ancora Health.