JMIR Publications

ABSTRACT

Background:

Avoidable rehospitalisation and frequent emergency department use in those with complicated chronic conditions are increasingly recognized as a complex, nonlinear process shaped by dynamic interactions between clinical, psychosocial, and contextual factors. The Patient Journey Record (PaJR) system was developed to address these challenges by operationalizing complexity science, narrative medicine, and anticipatory care within a telehealth-enabled coaching framework.

Objective:

This program descriptive study provides a narrative overview of the theoretical foundations, iterative development, and real-world implementation of the PaJR system. It also summarizes key findings from evaluative studies conducted across multiple healthcare settings.

Methods:

The evolution of PaJR is traced through pilot and implementation studies in Ireland and Australia, with iterative refinement informed by stakeholder feedback, patient experience, and workflow integration. Evaluative approaches included pragmatic controlled trials, service evaluations, and case vignettes, focusing on outcomes such as hospital utilization, patient satisfaction, and care coordination.

Results:

The PaJR system integrates structured telehealth conversations, predictive alerts, and relational coaching to support early detection of deterioration and adaptive care planning. Across diverse deployments, PaJR has demonstrated reductions in inpatient bed-days, improved care coordination, and high patient satisfaction. Case examples illustrate the model’s adaptability for patients with complex needs in urban, rural, and telehealth contexts. Key enablers include a lightweight digital platform, transdisciplinary teams, and localized “neighbourhood of care” structures.

Conclusions:

This narrative and programmatic overview demonstrates how the PaJR system translates complexity-informed theory into practical, scalable interventions for chronic care. Evaluative studies to date support its effectiveness in reducing avoidable hospitalizations and enhancing patient enablement. The synthesis highlights both the promise and challenges of implementing anticipatory, human-centered care models in real-world health systems.