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Related Concept Videos

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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Clinical Variables Associated with Physician-Driven Inclusion in a Special Management Program for Complex Patients.

Vered Mintzer1,2,3, Eugene Merzon1,2, Ariel Israel2,4

  • 1Adelson School of Medicine, Ariel University, Ariel 40700, Israel.

Journal of Clinical Medicine
|January 10, 2026
PubMed
Summary
This summary is machine-generated.

Complex patients with multiple chronic conditions, including respiratory and cardiac issues, are more likely to be enrolled in the "Team Management for Complex Patients" (TMCP) program. This program aims to improve care for these high-need individuals.

Keywords:
complex patientsmultiple chronic conditionsteam care management

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Area of Science:

  • Health Services Research
  • Clinical Medicine
  • Chronic Disease Management

Background:

  • Modern medicine faces challenges managing patients with multiple chronic somatic and/or mental disorders.
  • Specialized management programs are increasingly necessary for complex patient populations.
  • Identifying factors for inclusion in such programs is crucial for effective resource allocation.

Purpose of the Study:

  • To identify clinical variables and health service utilization associated with primary physician-driven enrollment into the "Team Management for Complex Patients" (TMCP) program.
  • To understand the characteristics of complex patients selected for a specialized care management program.

Main Methods:

  • A case-control study using electronic medical records from a nationwide health maintenance organization.
  • Propensity score matching was used to compare patients in the TMCP program with similar complex patients not enrolled.
  • Matched parameters included demographics, socioeconomic status, lifestyle factors, and baseline clinical measurements.

Main Results:

  • Patients enrolled in the TMCP program had significantly higher prevalence of respiratory, cardiac, gastrointestinal, neurological, inflammatory, and autoimmune diseases.
  • TMCP enrollees showed increased prior utilization of urgent care, emergency departments, hospitalizations, and medication use.
  • The control group was well-balanced, with exceptions in regional representation and physical activity levels.

Conclusions:

  • The study identified clinical variables and health service use patterns associated with the selection of complex patients for the TMCP program.
  • These findings can inform the development of objective criteria to support physician decision-making in patient management.
  • Future work should focus on validating selection criteria and optimizing healthcare resource allocation for high-need patients.