JMIR Publications

ABSTRACT

Background:

There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multi-morbid elderly. International health organizations propose digitally supported complex transformations towards: 1) person-centered care (PCC), 2) integrated and 3) proactive care. However, considerable uncertainty regarding both the design and effects of such digitally supported care transformations remain. Previous reviews have found favorable but unstable impacts ofTo describe how the literature on whole system complex transformations directed at frail elderly reflect 1) operationalization of intervention, 2) maturity, 3) evaluation methodology, and 4) effect on outcomes. each key element, but the maturity and synergies of the combination of elements are unexplored.

Objective:

To describe how the literature on whole system complex transformations directed at frail elderly reflect 1) operationalization of intervention, 2) maturity, 3) evaluation methodology, and 4) effect on outcomes.

Methods:

We performed a systematic health service and e-health literature review of care transformations targeting frail elderly. Papers including 1) PCC, 2) integrated, 3) proactive care, 4) at least one digital support element and 5) an effect evaluation with patient, health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure condensed descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the idealized and empirical intervention descriptions to create a new “Maturity of PCC model” which outlines the generic elements of a mature digitally supported PCC system. The authors then reviewed each intervention regarding maturity, study design quality, and intervention effects.

Results:

Of 927 potentially eligible papers, ten papers fulfilled the inclusion criteria. PCC was an ideal, but only one intervention made “what mattered” to the person visible in the care plan. Other care plans were described mainly in professional terms. Care coordinators responsible for a whole person care-plan, shared electronically in some instances, was the primary strategy countering care fragmentation. No studies report monitoring of care delivery. Risk stratification and management are mostly digitally supported and is the main proactive strategy. No intervention included workflow optimization nor patient-reported outcomes. The “Maturity of PCC model” showed how most interventions had one mature domain only. After study methodology assessment we included four studies in the outcomes summary. Three studies reported no effects while the fourth study found a 30% significant reduction in emergency care utilization.

Conclusions:

The person-focus in this literature is growing, but patients are still not in charge. The understanding of the synergies and interdependencies between elements of care is weak. The support from digital tools was patchy, and a socio-technical design of patient pathways was difficult to find. We predict that consistent results from complex care transformation efforts for frail elderly will only be achieved when the individual care pathway reflects a synergetic PCC, integrated and pro-active approach.