The Patient Centered Team (PACT) intervention - How does it work and for whom?


5% of the population spend 50% of all specialist care resources. These patients, often with complex long-term needs (CLNs), experience a fragmented care system ill prepared to provide for their needs. An extensive body of research indicates that critical elements of high-quality care for persons with CLNs include digital supported Person-centred, Integrated and Proactive care (PIP-care). Yet, outcome evaluations of PIP-care in the literature remain weak with a high proportion of negative studies.

The PIP-principles inspired the design of the Patient Centred Team (PACT). We started with PIP-care as our goal, and asked professionals to invent the care that would work in their context. PACT has subsequently demonstrated surprisingly consistent and strong results: “Compared with propensity score matched controls, the care process of frail multi-morbid elderly who received the PACT intervention had a reduced risk of high-level emergency care, increased use of low-level planned care, and substantially reduced mortality risk.”

To learn more from these very encouraging findings, we must now work backwards to get a detailed understanding of how PACT caused these positive effects, and who may benefit most. This knowledge is essential to improve the future care of patients with CLNs.

This study will also support a much needed care quality improvement for this costly and vulnerable group in both regional, national and international care contexts.


The overarching goal is:

To create a deeper understanding of how the successful PACT intervention works for persons with CLNs and identify those who benefit most.

This will be investigated by answering following research questions:

  1. How is comprehensive care delivered after a high-risk emergency admission?
  2. How does comprehensive care differ from usual care after a high-risk emergency admission?

Utility: Validation of widely recommended PIP-principles.


In this project we will apply a qualitative method to answer the research questions.

Medical audits build on the assumption that it is possible to formulate an idea of what is the desirable ideal clinical pathway, based on diagnosis specific evidence-based guidelines. However, for multimorbid patients the complexity of interactions between diagnosis, treatments and the person’s life and context, quickly make attempts to create combinatorial guidelines a quagmire of possibilities and uncertainties. We are therefore developing another qualitative approach.

As the typical PACT patients are often cognitively impaired, too ill to manage interviews, or have already died in the follow-up period, we need to base our review on available written documentation from the electronic health care record (EHR) from GPs, the municipal health services and hospitals.

With this as our main information source, we will do a qualitative analysis of the available EHR documentation for a selection of PACT patients and control-patients with high risk of death or death as the outcome, to identify the care processes after an emergency admission in hospital. We aim to identify the challenges for each patient, both of medical and non-medical, contextual origin and how these challenges are managed in the healthcare system. Finally, we will also look for differences between PIP-care and usual care. We will specifically look for traces of the PIP-care model in which the PACT intervention is inspired of.

Progress report

We have secured access to the EHR documents for a total of 18 PACT- and control patients and have started our qualitative review of the patient courses.