Effectiveness and Cost-effectiveness of Interdisciplinary Teamwork in Medical Emergencies: The PAtient-Centred Team (PACT) Service Model. Effect and Cost Effectiveness Evaluation

Paradoxically, the very success of our health care system causes the number of patients with multiple are on the rise. Studies of European populations above 75 years of age show LTC-prevalences of more than 70%, and rates of multimorbidity around 40-50%(8-10). Patients with LTC-conditions accounted for 3/4ths of health care spending in an early US report, and patients with 4 or more co-morbidities consumed 5 times as much health services as those with no LTC in a recent Irish report. The current care system is designed to deliver disease specific, urgent/ episodic care, and is poorly suited to the needs this growing patient group

Best practice models for patients with Long Term conditions (LTCs) and complex needs have been developed. In medicine, the underlying models are often implicit, which can cause the misunderstanding that medical research is practical, factual and not theory driven. In complex interventions, underpinning theoretical models are considered essential for study design.. In the planning and design of this intervention, the investigators have chosen to use the Chronic Care Model (CCM). Other models of chronic care are either slightly overlapping or in alignment with the CCM, but none of them cover all the areas of the CCM. It is the only model with both a systems- a clinical- and a patient perspective. Furthermore it has a growing evidence base for its effects on both care-processes, health outcomes and cost-effectiveness. It continues to inspire care reform both in large international care organizations, and in our local northern Norwegian context. The CCM builds on two pillars: "The informed active patient" and "The pro-active prepared health care team", which are equal partners engaging in "productive interactions" for "health and functional outcomes". Evidence Based Medicine (EBM) is the basis for identification of appropriate actions. Integrated team care delivery is then tailored to the patients' needs, values and preferences. Both health management support and use of clinical information systems are included in the model as key supporting factors(33).

A recent report documents that the health care delivery in Helse Nord is far from the ideal CCM-care. The main challenges were a lack of attention to the patient's personal context and priorities, and a fragmented care delivery. A large-scale CCM inspired project which answers these challenges, is under development at the university Hospital of North Norway (UNN). Its dual focus is coordination of care through two core components: 1) the proactive, prepared interdisciplinary teams with personnel from both hospitals and the municipalities to address the current fragmented care delivery and 2) the informed active patient approach to care planning. The initiative, which will be funded by redeploying existing staff to work in the teams. The team will facilitate patient centered and integrated care by conducting a structured person centered need assessments, develop individual evidence based care plans, and provide service integration across levels of care.

Research questions, hypotheses and methods The CCM is currently established as best practice for LTC-care delivery. Yet, the evidence of effectiveness of the CCM in terms of health and functional outcomes in several systematic reviews remain inconsistent. All CCM interventions, must tailor the CCM to local historical, cultural and regulatory context. Thus the heterogeneity of CCM-interventions is large, which may explain the observed inconsistencies. In our review, the investigators noted that many CCM-interventions seemed to lose the link to the underlying theory in the operationalization process. Active two-way patient-provider dialogues and practical skills development in self-management are central for better outcomes. However "the informed active patient" and "self-management support" were often translated into passive one-way educational interventions. Furthermore, the content of many of the CCM-interventions was often inadequately described, making it difficult to ascertain their fidelity to the underlying theory.

Our research questions are: What is the effect of a theory driven CCM-implementation on: