TimelyCare – Can a proactive Primary Care model deliver appropriate care for individuals at risk of high care consumption, and impact patient experienced continuity, healthcare utilization, and costs?

Research problem, specific questions The healthcare system faces challenges in delivering seamless, efficient and timely care, especially for a relatively small population that consumes a disproportionate amount of emergency care resources.

This proposal aims to co-create, optimize, implement, and evaluate a proactive primary care model (TimelyCare) in which patients at risk of high care consumption are identified, and provided with coordinated care at the primary care level.

Specific aims are to: Develop a measure that predicts individuals at risk for unplanned hospital care consumption based on morbidity and sociodemographic location. Co-create working routines for TimelyCare.

Investigate the impact of TimelyCare on patient-experienced continuity of care, healthcare consumption, and assess whether TimelyCare is cost-effective. Evaluate and deepen the understanding of the implementation process of TimelyCare.

Data and method  The project employs a co-design approach with comprehensive evaluation methods, including assessing intended outcomes through a clinical trial, using systematic frameworks, health economics, and analyzing patient/staff experiences of the new primary care model.

The clinical trial employs a stepped wedge, cluster - control design with an open cohort which is relevant as we follow a gradual introduction of the primary care model in natural settings, and patients may enter and leave the cohort during the evaluation period.

Societal relevance and utilization The TimelyCare project tackles the societal need for an optimized healthcare by focusing on the management of a vulnerable population with high healthcare usage in primary care. Its goal is to shift from reactive to proactive healthcare models.

The project’s significance lies in anticipating patient needs before they escalate, achieved through a multimodal primary care intervention and early identification of at-risk individuals.

Plan for project realization Interdiscilinary researchers from Linnaeus and Uppsala University collaborate closely with partner organizations in Kalmar Region and municipalities. They contribute to co-creation, implementation, participant recruitment, and data management. Researchers invest their own time and receive partial project funding.

Collaborating partners contribute their expertise and receive equivalent reimbursement as per the budget. TimelyCare’s individual components are currently tested in pilot projects, ensuring a swift project start.