Highlights
The PACE-It program significantly improved glycemic control, with 22.2% of participants achieving HbA1c levels below 7.5%, compared to only 9.1% in the usual care group. Participants in the integrated care model demonstrated superior lipid management, with 80.0% reaching LDL targets under 2.6 mmol/L. The intervention fostered substantial gains in patient activation and medication adherence, doubling the proportion of patients reaching high activation levels (PAM scores 3 and 4). Technology-enabled communication platforms were instrumental in reducing information asymmetry between health and social care sectors.
Introduction: The Crisis of Fragmented Care in Multimorbidity
Providing high-quality care for individuals with multimorbidity remains one of the most significant challenges for modern healthcare systems. In many jurisdictions, including Singapore, health and social care systems have historically operated in silos. This fragmentation often leads to information asymmetry, where medical providers are unaware of a patient’s social determinants of health, and social workers lack critical clinical context. The result is a duplicated service landscape, fragmented care pathways, and poor clinical outcomes for the most vulnerable populations. Individuals with poorly controlled diabetes mellitus often present with complex psychosocial needs—ranging from financial instability to lack of social support—that cannot be addressed by medical interventions alone.
The PACE-It Model: An Integrated Multidisciplinary Approach
The PACE-It (PrimAry CarE based Integrated community care Team) program was designed to address these systemic gaps. Developed in a public primary care setting in Singapore, the program centers on a person-centered care model that bridges the divide between clinical medicine and social support.
A Multidisciplinary Team Structure
At the heart of PACE-It is a multidisciplinary team (MDT) that includes primary care physicians, nurses, and social care workers. Unlike traditional referral-based models, the PACE-It MDT works collaboratively to co-develop care plans. This structure ensures that clinical goals (such as glycemic control) are aligned with the patient’s social realities (such as food security or housing stability).
Technology as an Enabler of Integration
A cornerstone of the PACE-It intervention is the use of a technology-enabled secure communication platform. This digital infrastructure allows for real-time information sharing between health and social care professionals. By providing a single point of truth for a patient’s progress, the platform mitigates the risk of fragmented advice and ensures that all stakeholders are working toward the same person-centered objectives.
Study Design and Evaluation Methodology
To evaluate the efficacy of the PACE-It model, researchers conducted a pilot randomized controlled trial (RCT) between December 2020 and February 2022. The study enrolled 41 participants characterized by poorly controlled diabetes and significant complex psychosocial needs. Participants were randomized to either the PACE-It intervention or the usual care group. The primary endpoints included clinical markers (HbA1c and LDL-C levels) and patient-reported outcome measures (PROMs), specifically the Patient Activation Measure (PAM) and the Medication Adherence Report Scale (MARS-5). The evaluation period spanned 12 months, providing a robust look at the sustainability of the intervention’s effects.
Key Findings: Clinical Outcomes and Patient Empowerment
The preliminary findings from the PACE-It pilot suggest that the integrated approach is significantly more effective than traditional care models for complex patients.
Glycemic and Lipid Control
Clinical data at the 12-month mark revealed a stark difference between the two groups. In the PACE-It cohort, 22.2% of patients achieved an HbA1c < 7.5%, more than double the rate seen in the usual care group (9.1%). Even more impressive were the results for lipid management; 80.0% of the PACE-It group achieved an LDL < 2.6 mmol/L, compared to 57.1% in the control group. These findings suggest that addressing psychosocial barriers directly impacts a patient's ability to achieve physiological targets.
Patient Activation and Medication Adherence
The study also highlighted significant improvements in how patients engage with their own health. Patient activation—the knowledge, skills, and confidence a person has in managing their own health—was measured using the PAM score. At 12 months, 43.8% of PACE-It participants reached high activation levels (Levels 3 and 4), compared to only 23.3% in the usual care group. Medication adherence also saw a positive trend, with 9.5% of the intervention group achieving a MARS-5 score of 20 or higher, nearly double the 4.4% observed in the control group.
Expert Commentary: Breaking the Silos
The success of PACE-It underscores the importance of the ‘Relationship-Based Care’ philosophy. Beyond the quantitative data, the program’s evaluation noted that the co-development of the PACE-It model led to significantly stronger relationships and collaboration between health and social care workers. From a clinical standpoint, this is crucial. When a physician understands that a patient’s non-adherence is due to the cost of transportation rather than a lack of willpower, and a social worker can facilitate that transport, the clinical outcome improves. However, it is important to acknowledge the limitations of this pilot. With a sample size of 41, the study is underpowered for broader generalizability. Large-scale trials are necessary to determine if these outcomes can be replicated across diverse demographics and larger health systems. Furthermore, the cost-effectiveness of maintaining a multidisciplinary team and a secure tech platform must be weighed against the long-term savings of reduced hospitalizations and complications.
Conclusion: Implications for Global Primary Care
The PACE-It program provides a compelling blueprint for the future of integrated care. By leveraging technology to break down communication barriers and fostering a truly multidisciplinary environment, the model successfully improved both clinical and patient-reported outcomes for high-complexity individuals. As healthcare systems globally shift toward value-based and person-centered care, models like PACE-It will be essential in moving beyond the clinic walls to address the holistic needs of the patient.
References
1. Oka P, Wang ZS, Hu PL, Lee CE, Ng CJ. PACE-It: An Integrated Multidisciplinary Technology-Assisted Approach to Person-Centered Care for Individuals with Complex Care Needs. Journal of General Internal Medicine. 2026. PMID: 41811605.
2. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Managed Care Quarterly. 1998;6(1):2-11.
3. Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Services Research. 2004;39(4 Pt 1):1005-1026.
