Stroke Transitional Care Use Case

Cancer Mission

The Gaps Between Care

A patient's hardest moments often come between one care setting and the next.

This RAISE Suite use case links real-world activity data with quantified rehabilitation exposure, supporting clinical decisions at the transitions where continuity of care is most fragile.

At a glance

Pilot Period

M6 – M40

(Feb 2026 – Dec 2028)

Partners Involved
Domain

 Health — Transitional Care & Neurorehabilitation

Location / Study Sites
  •  Thessaloniki (GR)
  • Valladolid (ES)
  • Montreal (CA)
Participants / Scale
  •  60 patients across three clinical sites

Main Goal

This use case investigates how real-world physical activity and quantified exposure to rehabilitation interventions relate to changes in clinical and patient-reported outcomes, supporting decision-making in transitional care.

The moments when a patient moves from hospital to home, or from inpatient to outpatient rehabilitation, are where continuity of care is most easily lost. By combining wearable-derived digital biomarkers, clinical assessments, patient-reported outcomes, and data on the rehabilitation that patients actually receive, the pilot captures how functional status evolves through these transitions, and gives clinicians the evidence to act on it.

The study is designed as a prospective, multi-site pragmatic cohort study with a structured intervention framework applied across all sites. 

Domain Challenges

  • Care that spans disconnected settings: Patients move between hospital, home and rehabilitation centres, but the data follows them poorly, leaving clinicians with an incomplete picture at exactly the moments decisions matter most.
  • Rehabilitation exposure goes unmeasured: How much therapy a patient actually receives, and how they engage with it, is rarely quantified, making it hard to link intervention to outcome.
  • Data locked behind regulation and fragmented tools: Strict privacy rules limit exchange between institutions and across borders, while devices, questionnaires and clinical records sit in separate systems with no common structure.

Keywords

health, stroke, transitional care, neurorehabilitation, rehabilitation, multimodality, digital biomarkers, wearables, smart devices, patient-reported outcomes, data privacy, data interoperability, FAIR data

Key Figures & Facts

The pilot adopts a multimodal, clinically integrated approach across three sites, AUTH (Greece), INTRAS (Spain) and McGill (Canada), combining clinical outcomes, patient-reported questionnaires, daily smart-device data, and quantified rehabilitation exposure captured through the Gradior Suite.

Explore the interactive image below for the full picture of what is collected, how, and with which tools.

Scale & Study Area

60 patients across three clinical sites in Greece, Spain and Canada.

Platform

Three care settings:

  • hospital
  • home
  • rehabilitation

with the RAISE Suite SDK deployed close to the data sources.

Data types

Four streams:

  • pre- and post-intervention clinical outcomes
  • pre- and post-intervention questionnaires
  • daily smart-device data
  • quantified rehabilitation intervention data
Devices & Questionnaires

Wearables and smart devices capturing real-world physical activity and digital biomarkers across all three care settings.

The questionnaires to be used are: 

  • Mobility (Berg Balance Scale, Functional Gait Assessment)
  • Mental and emotional strain (PHQ-9)
  • Quality of life (PROMIS-29/SF-12, EQ-5D-5L)

 

 

Gradior Suite

A neuropsychological intervention platform supporting rehabilitation across cognitive, physical, sensorial-emotional and social dimensions — contributing quantified therapy exposure data.

Approach & Study Design

A shared machine-actionable Data Management Plan (ma-DMP) harmonises this study with the Cancer use case for cross-site analysis, following a prospective, multi-site pragmatic cohort study with a structured intervention framework applied across all sites.

Use Case Implementation Phases

May–December 2026
Data Collection Without RAISE
A baseline cycle using existing tools and workflows. Clinical, device and rehabilitation data are collected across care settings as normal, establishing the reference point against which RAISE Suite's impact will be measured. Ethical approval is secured in September 2026, with first participants enrolled at each site from October 2026.
May–December 2026
January– April 2027
SDK Integration & RAISE Onboarding
The RAISE Suite SDK is deployed close to the data sources across all sites. The team onboards to the RAISE Portal, creates the shared machine-actionable Data Management Plan (ma-DMP), describes datasets with FAIR-aligned metadata, and connects instruments to the automated ingestion pipeline. Over 20% of the participant cohort is enrolled by January
January– April 2027
May 2027 – May 2028
Data Collection with RAISE
The same collection cycle is repeated, now powered by RAISE Suite: multimodal data is captured automatically via the SDK and managed and analysed on the RAISE Portal, ending in a FAIR-compliant, privacy-preserving dataset and a scientific publication.
May 2027 – May 2028

Use Case Outcomes

Decision Support at the Transitions

Linking Activity, Therapy and Outcomes

A multimodal dataset connecting real-world activity and quantified rehabilitation exposure to clinical and patient-reported outcomes, supporting decisions in transitional care.

A Harmonised Collection Protocol

One ma-DMP, Three Countries

A common, FAIR-by-design data collection protocol validated across transnational sites in Greece, Spain and Canada, assessed for data quality and interoperability.

FAIR Data in a Regulated Field

Interoperable, Compliant, Reusable

Proof that RAISE Suite can deliver interoperable, high-quality health data collection under strict privacy regulation, including sharing beyond the EU.