Integrated care programme for patients with type 1 diabetes who use an insulin pump, improved with digital technology

INCAP provides an integrated care programme for people who have type one diabetes and use an insulin pump. The solution is built on three pillars:

  • a remote monitoring support centre, to optimise control of the disease for each individual patient;
  • an educational programme to empower patients;
  • a communication channel connecting the hospital to primary carers.


Patients with chronic conditions need integrated care, and hospitals need to be able to provide such care. INCAP seeks to meet these needs for patients who rely on Continuous Subcutaneous Insulin Infusion (CSII, commonly called an insulin pump), by providing a holistic solution that has a positive impact on health outcomes, allows greater patient empowerment and improves communication between all the actors involved in care of patients. This support is important because stable patients with peace of mind enjoy better outcomes.


  • Dr. Ros, Chief of section of the Pediatric Department at HUPHM, clinical leader.
  • Dr. Giuseppe Fico (UPM) coordinator of the Education and Empowerment subgroup within the Action Group A1 – Adherence to Treatment of the EIPonAHA.
  • Belén Núñez (Medtronic), pharmacist with more than 10 years of experience in different areas in the medical devices industry. She is responsible for the CSSR.
  • Dr. Steven Flipse, expert in training and responsible innovation, from TUD, will be in charge of the training and education services.
The project

The project establishes an integrated system to follow up and provide continuity of care for type 1 diabetes patents who use Continuous Subcutaneous Insulin Infusion – an insulin pump. The care includes a Remote Monitoring Support Centre, which delivers an efficient and comprehensive service for device management, combined with an educational programme for patients and their relatives, to empower them for better self-management of the disease, increased adherence to treatment and improved clinical results.

The project uses remote digital technology to meet two very important needs that are currently not addressed by the healthcare system:

  • Establishing a communication channel between the hospital and the patient. Information taken from remote monitoring of the insulin pump is presented as feedback to the patient, and reinforces the education/nutrition/exercise information that the patient received in the hospital.
  • Establishing a coordination system between the hospital, and the primary carer to complete the comprehensive follow-up of the patient, involving all the stakeholders.



The INCAP project will have a positive impact on:

  • Patients and their families, because it ensures better continuity of care and empowers patients to take better care of themselves, resulting in improved health.
  • Hospitals, because it helps them communicate with patients and primary carers, thereby improving the results of their treatment.
  • Payers, because monitoring ensures more efficient long-term care of chronic conditions.
Why this is an EIT Health project

This project promotes active ageing by helping patients handle a chronic disease. It is in keeping with the EIT Health Focus Area of “Bringing Care Home”, because it empowers type 1 diabetes patients who have an insulin pump to live at home while still enjoying monitoring from healthcare professionals and while benefitting from digital feedback that helps them take better care of themselves.

This project will provide a significant improvement of clinical and healthcare outcomes in T1DM patients treated with CSII by means of improved self-management capabilities, increased adherence to treatment and the achievement of educational and motivational goals, allowing the anticipation of adverse events and disease complications.

Dr. Ros, project clinical leader

Belén Riquelme
| Directora FIB HUPHM | SERMAS