Understanding Clinical Complexity the Hard Way: A Primary Care Journey

Area of Science:

• Primary Care Medicine
• Health Services Research
• Complex Care Management

Background:

• Primary care settings are increasingly encountering patient complexity.
• This complexity is characterized by multiple concurrent chronic conditions and social determinants of health.
• Traditional primary care models face substantial challenges in addressing these evolving patient needs.

Purpose of the Study:

• To document evolving approaches in academic family practice for managing complex patients.
• To describe the development, implementation, and evaluation of an inter-professional model of care.
• To explore innovations in policy, clinical practice, and service delivery for complex populations.

Main Methods:

• Review of approaches in an academic family practice environment.
• Description of research leading to an inter-professional model of care.
• Evaluation of the model's outcomes and subsequent clinical and research evolution.

Main Results:

• Development and implementation of an inter-professional model of care.
• Demonstration of associated outcomes in managing complex patients.
• Evolution of clinical models and research to reframe complexity and drive innovation.

Conclusions:

• The inter-professional model of care offers a framework for addressing primary care complexity.
• Further research and policy innovations are needed to support complex patient populations.
• 15 years of experience highlight significant challenges and opportunities in complex care research and practice.