Types of Care models
Integrated Model of Care (IMC) (33–53): The IMC has been implemented across Europe, Spain, Italy, Canada, the United States, Australia, China, and Taiwan, with related initiatives like Canada's PRISMA program. This model operates in various settings, including hospitals, community geriatric units, chronic disease clinics, and nursing homes. Essential components of the ICM include organizational arrangements, patient recruitment, multidisciplinary team collaboration, comprehensive service delivery, financial management, and the use of ICT-based platforms like e-health records. Specifically, teams comprise case managers, physicians, specialists, pharmacists, geriatric practitioners, general practitioners, social workers, psychologists, project managers, and occupational therapists. Service delivery involves assessments, care planning, management, follow-ups, medication reviews, care coordination, patient empowerment, self-management, and effective communication.
The impacts of the ICM are significant, leading to improved quality of care, better health outcomes, cost efficiency, and enhanced patient satisfaction. However, challenges include resource allocation, team coordination and communication, service integration, technological barriers, and policy and regulatory hurdles. Facilitators for successful implementation include strong leadership and governance, supportive policies, continuous professional training, access to community and social resources, adequate financial support, and effective use of health information systems and digital tools. These elements underscore the comprehensive nature of the ICM and highlight the coordinated efforts needed to meet the complex healthcare needs of patients with multiple long-term conditions.
Collaborative Care Model (CCM) (54–62): The CCM has been studied in various settings, including a safety net clinic for low-income Hispanic patients, primary care clinics in the USA, general practices in Australia, and Northwest England. It involves selectively engaging healthcare professionals based on their roles and contributions. For instance, social workers, psychiatrists, and primary care physicians (PCPs) are involved in managing depression and diabetes. In these cases, bilingual social work specialists and PCPs deliver problem-solving therapy and prescribe antidepressants, respectively. While social workers and PCPs play primary roles, they receive supervision from higher-level professionals, with psychiatrists providing telephone consultations for medication management. In managing diabetes and coronary heart disease, practice nurses and psychological practitioners deliver case management and low-intensity psychological treatment.
Essential components of the CCM include a well-trained health workforce, a multidisciplinary team, case management, comprehensive assessments, care planning, drug prescriptions, problem-solving therapy, and psychological therapy. It emphasizes client support, including self-care with pharmacotherapy, guideline-based drug preferences, motivational coaching, self-monitoring materials, and follow-up activities. Monthly telephone follow-ups, bi-weekly visits, outreach visits, and weekly case review meetings are integral to this model. The impacts of the model include improved patient care coordination and treatment outcomes. However, challenges such as ensuring adequate training, maintaining effective collaboration among diverse professionals, and managing communication barriers must be addressed. Facilitators for this model include strong leadership, continuous professional training, and supportive policies to ensure effective implementation. CCM improved quality of care (client satisfaction, recovery), increased recipient of treatment, reduced costs of care, and improved quality of life. In contrast, this care model was not effective on pain management among individuals with depression and musculoskeletal problems, as well as in improving depression among individuals with diabetes or cardiovascular diseases.
Integrated- Collaborative Care Model (63): The Integrated CCM evaluated in general practices in northwestern England, aims to address the needs of individuals dealing with depression and chronic conditions like diabetes or cardiovascular disease. This model operates through two distinct intervention phases. Initially, collaborative care is provided by psychological practitioners, focusing on psychological well-being and symptom management. Subsequently, care is integrated jointly with the practice nurse, emphasizing comprehensive patient assessment, care plan development, and various symptom management techniques such as behavioral activation and cognitive restructuring. Key components also include training for psychological practitioners, collaborative care meetings involving patients, practitioners, nurses, and general practitioners for medication management, as well as rigorous monitoring and supervision by experienced psychological therapists on a weekly basis.
The model underscores the importance of follow-up care, with weekly follow-ups for clients facing more complex issues and monthly follow-ups for others. Implementations typically occur within general practice clinics or psychological therapy centers, ensuring accessibility and consistency in the treatment environment. While the Integrated CCM has shown positive impacts on patient outcomes, challenges include ensuring adequate training for practitioners, fostering effective collaboration among team members, and managing the coordination of care across different settings. Facilitators for successful implementation encompass robust training programs, effective communication strategies, supportive leadership, and patient engagement. These elements are crucial for optimizing care delivery and addressing the multifaceted needs of individuals with depression and long-term physical conditions within the Integrated CCM framework. IMC improve quality of care (client satisfaction and recovery), accessibility (increased patient’s clinical visits), patient-centredness communication between levels of care, safety (reduce medication errors and facilitate home death), efficiency (shorten hospitalization and reduced unnecessary services uses), quality of life, and foster self-management. However, this model did not yield in significant differences in quality of life, self-efficacy, disability, and social support.
Guided Care Mode (GCM) (64–66): The GCM, implemented in primary care offices in the USA, comprises several essential components aimed at improving patient care. These elements, viewed as guiding principles, include meticulous planning, comprehensive training for healthcare providers, and thorough patient assessment primarily conducted by nurses. Collaboration among interdisciplinary team members, including nurses, physicians, patients, and caregivers, is emphasized to ensure holistic care delivery. Central to the model is the development of personalized care plans tailored to each patient's needs, alongside disease or case management services provided by the healthcare team. Regular follow-up, monitoring, and evaluation are integral to track patient progress and adjust care plans accordingly. Additionally, the model emphasizes support for patient self-management, encompassing lifestyle modifications, as well as coordination of care among healthcare professionals and seamless transitions between care settings. Adequate allocation of resources is also highlighted to ensure the effective implementation of the model.
The GCM has significant impacts on patient outcomes, including improved quality of care, enhanced patient satisfaction, and better health outcomes. However, challenges exist, such as ensuring sufficient training for healthcare providers, fostering effective collaboration among team members, and managing the coordination of care across various healthcare settings. Facilitators for successful implementation include robust planning processes, comprehensive training programs, effective communication strategies, and access to adequate resources. Additionally, supportive policies and leadership, alongside patient and caregiver engagement, are crucial for overcoming challenges and optimizing the delivery of care within the GCM framework. GCM increased quality of care and acceptability of services.
Nurse-led Care Model (NCM) (67–69): This model was developed with a multidisciplinary team in Australia to support continuity of care at the primary-secondary interface for people with multimorbidity. NCM, led by nursing professionals, was also evaluated in Japan, the USA, Canada, UK, Australia, Netherlands, New Zealand, and Slovenia. Elements were coordination, governance, communication, culture, health assessment, develop care process or care plan (e.g., self-management action plan), collaboration (patient and care provider), clinical best practice and interventions (psychological support), evaluation & improvement, and systems, processes and resources. Multidisciplinary involvement was also emphasised in this care model i.e., coordinated multidisciplinary intervention. NCM was acceptable to physician, patients, and caregivers and transferrable to other health care settings.
Chronic Care model (CMC)
It was implemented for multiple chronic conditions in primary care and promoting effective advance care for elders in the USA. The first step in adopting CMC is healthcare organization, involving leadership, incentives, resources, support, and area agency. Number of clinics, number of physicians, number of physicians per clinic, types of specialities, years of physician’s experiences, productivity per month, payer by clinic, intermountain health plan are part of the organization. Care delivery redesign is the second major element that includes care management encounters, face to face visits, telephone calls, coordination, and care conferences. Self -management support includes education sessions and motivation of patient. Electronic accesses and connection to external programs are involved as part of connection to community. Using protocols was part of support for evidence-based practice. Monthly information system usage used for access, best practice support, and communication by participating care managers and physicians (70). The Promoting Effective Advance Care for Elders (PEACE) (71) model, which was evaluated in the USA, utilised CMC’s interventions.
Several care models have been explored but are not frequently investigated. The Geriatric Care model, developed in the Netherlands, focuses on enhancing the health conditions of the elderly (72). The Geriatric Care model did not effectively improve quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning, or reduce hospitalizations (72). In the USA, the All-inclusive Care for the Elderly (PACE) model (73), Care Coordination (62), and Care management Plus (74) were evaluated .The IMPACT clinic (75) and Value stream mapping (76) in Canada represents an innovative model of interprofessional primary care for community-dwelling seniors and patient waiting time enhancement model. The Preventive Home Visit in Japan involves the assessment of locomotion, daily activities, social contacts or relationships with other people, health conditions, and signs of abuse by community health nurses, care managers, or social workers (77). Lastly, Transitional Care conducted in Chile involves a transition nurse who establishes a transition office, communicates via email, identifies patients, and reviews clinical records (78). The overview of common care models with their essential components, impacts, challenges, and facilitators are presented in Table 1.
Table 1: Care models, essential elements, impacts, challenges, and facilitators