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 supported Person-centered, Integrated and Pro-active (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 complex long-term needs.

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 Complex long-term needs and identify those who benefit most.

This will be investigated by answering following research questions:

  1. Why did the activities of the Patient Centred Team (PACT) reduce emergency care and mortality?
  2. Utility: Critical knowledge for the improvement of care for future multi-morbid patients.
  3. How were the elements of Person-centered, Integrated and Pro-active (PIP) care documented and delivered?

Utility: Validation of widely recommended PIP-principles.


This project will apply mixed methods, where we use quantitative and qualitative data as needed to answer the research questions.

Medical audit builds 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 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 have 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 and qualitatively answer a set of questions for each patient. The questions will concern information about what matters to the patient, what are the risk factors for the patient and which measures are implemented, as well as a discription of the follow-up plan and the cooperation between the involved health care workers.

Based on the qualitative data review, we will try to summarize the answer to each question in a agree-disagree scale from 1-5 (totally disagree – fully agree), while developing a guide for how to score each question. This method will initially be trialed on 4 patients, and then evaluated. We then plan to do the same review of around 20 PACT patients and their controls.

Progress report:

We have currently secured access to the full set of EHR documents (GP, the municipal health services and hospital) for 4 test patients, and are about to start our qualitative review.

Project manager

Project participants

External project participants

  • Anette Fosse, UiT Norges Arktiske Universitet
  • Markus Rumpsfeld, Universitetssykehuset Nord-Norge
  • Monika Dalbakk, Universitetssykehuset Nord-Norge
  • Lisbeth Spannsvoll, Universitetssykehuset Nord-Norge
  • Brita Jørgensen, Universitetssykehuset Nord-Norge
  • Birgitte Forså Åbotsvik, Tromsø Kommune

Collaborating organisations


  • Helse Nord RHF


Patient pathways

Project period

2021 - 2023

Last updated

20 April 2021