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

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.