The Challenge of Multimorbidity: Bridging Clinical and Social Gaps
The management of patients with multimorbidity—defined by the presence of two or more chronic conditions—is one of the most pressing challenges facing modern healthcare systems. In many developed nations, including Singapore, the traditional medical model often fails these individuals because their health is inextricably linked to psychosocial determinants that clinical settings are poorly equipped to address. Health and social care systems typically operate in silos, characterized by information asymmetry, fragmented service delivery, and a frequent duplication of efforts. This fragmentation often leads to poor clinical outcomes, especially for patients with complex care needs such as poorly controlled diabetes and significant psychosocial barriers.
- Significant Clinical Gains: Participants in the PACE-It program were more likely to achieve glycemic and lipid targets compared to those in usual care.
- Enhanced Patient Empowerment: The program led to higher levels of patient activation and significantly improved medication adherence.
- Technological Integration: A secure communication platform facilitated real-time collaboration between multidisciplinary health and social care providers.
