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Related Concept Videos

Interdisciplinary Care: The Health Care Team-I01:21

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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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Related Experiment Video

Updated: Mar 13, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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PACE-It: An Integrated Multidisciplinary Technology-Assisted Approach to Person-Centered Care for Individuals with

Prawira Oka1,2, Zhen Sinead Wang3, Pei Lin Hu4,3

  • 1Department of Research, SingHealth Polyclinics, Singapore, Singapore. prawiraoka91@gmail.com.

Journal of General Internal Medicine
|March 11, 2026
PubMed
Summary

The PACE-It program improved clinical outcomes and patient activation for individuals with complex needs. This integrated care model enhanced collaboration between health and social care providers.

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Last Updated: Mar 13, 2026

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Area of Science:

  • Integrated care models
  • Health and social care systems
  • Multimorbidity management

Background:

  • Quality care for multimorbidity necessitates health and social care integration.
  • Current systems often operate in silos, leading to fragmented care and service duplication.
  • Addressing complex care needs requires bridging the gap between health and social services.

Purpose of the Study:

  • To describe and evaluate an integrated health and social care model for individuals with complex needs.
  • To assess the impact of the PACE-It program on clinical and patient-reported outcomes.
  • To foster collaboration between health and social care professionals.

Main Methods:

  • A pilot randomized controlled trial was conducted in a public primary care organization in Singapore.
  • The study involved individuals with poorly controlled diabetes mellitus and complex psychosocial needs.
  • The intervention, PACE-It (PrimAry CarE based Integrated community care Team), utilized a multidisciplinary team and a secure communication platform.

Main Results:

  • Participants in the PACE-It program showed improved clinical outcomes, including better HbA1c and LDL control compared to usual care.
  • Patient activation and medication adherence were significantly higher in the intervention group.
  • Specific improvements included higher achievement of HbA1c < 7.5% (22.2% vs 9.1%) and LDL < 2.6 mmol/L (80.0% vs 57.1%).

Conclusions:

  • The PACE-It integrated care model demonstrated preliminary success in improving clinical and patient-reported outcomes.
  • Co-development of the program fostered enhanced relationships and collaboration between health and social care workers.
  • Integrated care approaches are vital for managing complex patient needs effectively.