Designing a Person-Centred Integrated Care Programme for People with Complex Chronic Conditions: A Case Study from...

Area of Science:

• Gerontology
• Public Health
• Health Services Research

Background:

• Increasing prevalence of complex chronic conditions necessitates improved care models.
• High social and health needs of this population require integrated, person-centred approaches.

Purpose of the Study:

• To develop an evidence-based integrated care program for patients with multimorbidity and advanced conditions.
• To incorporate patient, caregiver, and professional priorities into a comprehensive care plan.

Main Methods:

• Conducted focus groups and semi-structured interviews with patients, caregivers, and patient association representatives.
• Synthesized patient/caregiver experiences with evidence-based recommendations from healthcare and social care professionals.
• Designed a care program integrating identified priorities across the care trajectory.

Main Results:

• Key patient and caregiver priorities include information comprehension, care coordination, social service access, caregiver support, perceived support, and home care.
• These priorities informed 37 of 63 clinical actions within the integrated care program.
• The program addresses various care stages: identifying high needs, care planning, crisis management, transitional care, and end-of-life care.

Conclusions:

• An evidence-based integrated care program was successfully developed for high-need patients.
• The program effectively combines insights from patients, caregivers, and healthcare/social care professionals.
• This tailored approach aims to meet the complex needs of individuals with chronic conditions.