Person-centred, integrated and pro-active care for multi-morbid elderly with advanced care needs: a propensity score-matched controlled trial

G K R Berntsen, M Dalbakk, J S Hurley, T Bergmo, B Solbakken, L Spansvoll, J G Bellika, S O Skrøvseth, T Brattland, M Rumpsfeld, G K R Berntsen, M Dalbakk, J S Hurley, T Bergmo, B Solbakken, L Spansvoll, J G Bellika, S O Skrøvseth, T Brattland, M Rumpsfeld

Abstract

Background: Person-centred care (PCC) focusing on personalised goals and care plans derived from "What matters to you?" has an impact on single disease outcomes, but studies on multi-morbid elderly are lacking. Furthermore, the combination of PCC, Integrated Care (IC) and Pro-active care are widely recognised as desirable for multi-morbid elderly, yet previous studies focus on single components only, leaving synergies unexplored. The effect of a synergistic intervention, which implements 1) Person-centred goal-oriented care driven by "What matters to you?" with 2) IC and 3) pro-active care is unknown.

Methods: Inspired by theoretical foundations, complexity science, previous health service research and a patient-driven evaluation of care quality, we designed the Patient-Centred Team (PACT) intervention across primary and secondary care. The PACT team collaborate with the patient to make and deliver a person-centred, integrated and proactive multi-morbidity care-plan. The control group receives conventional care. The study design is a pragmatic six months prospective, controlled clinical trial based on hospital electronic health record data of 439 multi-morbid frail elderly at risk for emergency (re) admissions referred to PACT and 779 propensity score matched controls in Norway, 2014-2016. Outcomes are emergency admissions, the sum of emergency inpatient bed days, 30-day readmissions, planned and emergency outpatient visits and mortality at three and six months follow-up.

Results: The Rate Ratios (RR) for emergency admissions was 0,9 (95%CI: 0,82-0,99), for sum of emergency bed days 0,68 (95%CI:0,52-0,79) and for 30-days emergency readmissions 0,72 (95%CI: 0,41-1,24). RRs were 2,3 (95%CI: 2,02-2,55) and 0,9 (95%CI: 0,68-1,20) for planned and emergency outpatient visits respectively. The RR for death at 3 months was 0,39 (95% CI: 0,22-0,70) and 0,57 (95% CI: 0,34-0,94) at 6 months.

Conclusion: Compared with propensity score matched controls, the care process of frail multi-morbid elderly who received the PACT intervention had a reduced risk of high-level emergency care, increased use of low-level planned care, and substantially reduced mortality risk. Further study of process differences between groups is warranted to understand the genesis of these results better.

Trial registration: ClinicalTrials.gov (identifier: NCT02541474 ), registered Sept 2015.

Keywords: Health care utilisation; Integrated care; Mortality; Person-centred care; Proactive care; Propensity score matched controls.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Inclusion and exclusion Flowchart. Legend: The figure shows eligible PACT patients and exclusions at the person level. The Patient-Centred Team (PACT)-study, Norway 2014–16
Fig. 2
Fig. 2
Mortality. Legend: Crude Kaplan-Meier curves, showing the proportion of patients alive by time, and group in 6 months follow-up period. Pooled data, (N = 1218). The Patient-Centred Team (PACT)-study, Norway 2014–16

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