Bridging the Health-Social Gap: The PACE-It Model Shows Promise for Complex Multimorbidity Management

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

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