IPCHS. Integrated People-Centred Health Services

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Contents tagged: complex care needs

April 19, 2021 Europe Publication

Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner’s Perspective

 
In public health services, aging and a high prevalence of multiple diseases as age increases are currently the norm rather than the exception, and challenge the single-disease model that prevails in medical education, research and hospital care. Individuals with multimorbidity do not show dominant combinations of conditions, and most clinical programs or guidelines for chronic disease management still focus on specific and single conditions. For these reasons, there is a growing concern that these programs may be less effective and even harmful for individuals with multimorbidity when compared to person-centred approaches.

In recent years, a new concept has been introduced, which is becoming increasingly common in primary care: the “complex chronic patient (CCP)”

The aim of this cross-sectional, population-based observational study is to identify sub-populations of complex chronic patients who could benefit from targeted care management approaches.

April 19, 2021 Global Publication

Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review

Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination.

This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare.

Nov. 26, 2020 Americas Publication

Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.

This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning ...

Nov. 28, 2019 Global Publication

The Development of a Logic Model to Guide the Planning and Evaluation of a Navigation Center for Children and Youth with Complex Care Needs

Most systems across health settings and sectors are not well integrated and do not provide the needed supports, resources, or access caregivers and families require to properly care for their child with complex care needs (CCNs). NaviCare/SoinsNavi is a research-based navigation center aimed to help facilitate more convenient and integrated care to support the needs of children, youth, and their families using a patient navigator to offer personalized family-centered care