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Background <p>Providing quality care for individuals with multimorbidity requires the integration of care across health and social care systems; however, the two systems often work in silos, resulting in information asymmetry, fragmented care, and the duplication of services.</p> Aim <p>To describe a model integrating health and social care for individuals with complex care needs.</p> Setting <p>A public primary care organization in Singapore.</p> Participants <p>Individuals with poorly controlled diabetes mellitus and complex psychosocial needs.</p> Program Description <p>PACE-It (PrimAry CarE based Integrated community care Team) program comprising an integrated multidisciplinary team and a technology-enabled secure communication platform.</p> Program Evaluation <p>A pilot randomized controlled trial (<i>n</i> = 41) was conducted between December 2020 and February 2022. Individuals enrolled in the PACE-It program had better clinical outcomes than those receiving usual care, with more achieving HbA1c &lt; 7.5% (22.2% vs 9.1%) and LDL &lt; 2.6&#xa0;mmol/L (80.0% vs 57.1%) at 12&#xa0;months. They also reported greater patient activation and medication adherence from baseline (PAM score 3 and 4, 43.8% vs 23.3%; MARS-5 ≥ 20, 9.5% vs 4.4%).</p> Discussion <p>Preliminary findings show improved clinical and patient-reported outcomes. Additionally, the co-development of PACE-It led to stronger relationships and collaboration between health and social care workers.</p>

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PACE-It: An Integrated Multidisciplinary Technology-Assisted Approach to Person-Centered Care for Individuals with Complex Care Needs

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年3月11日

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  • Prawira Oka,
  • Zhen Sinead Wang,
  • Pei Lin Hu,
  • Chien Earn Lee,
  • Chirk Jenn Ng

摘要

Background

Providing quality care for individuals with multimorbidity requires the integration of care across health and social care systems; however, the two systems often work in silos, resulting in information asymmetry, fragmented care, and the duplication of services.

Aim

To describe a model integrating health and social care for individuals with complex care needs.

Setting

A public primary care organization in Singapore.

Participants

Individuals with poorly controlled diabetes mellitus and complex psychosocial needs.

Program Description

PACE-It (PrimAry CarE based Integrated community care Team) program comprising an integrated multidisciplinary team and a technology-enabled secure communication platform.

Program Evaluation

A pilot randomized controlled trial (n = 41) was conducted between December 2020 and February 2022. Individuals enrolled in the PACE-It program had better clinical outcomes than those receiving usual care, with more achieving HbA1c < 7.5% (22.2% vs 9.1%) and LDL < 2.6 mmol/L (80.0% vs 57.1%) at 12 months. They also reported greater patient activation and medication adherence from baseline (PAM score 3 and 4, 43.8% vs 23.3%; MARS-5 ≥ 20, 9.5% vs 4.4%).

Discussion

Preliminary findings show improved clinical and patient-reported outcomes. Additionally, the co-development of PACE-It led to stronger relationships and collaboration between health and social care workers.