Project: TimelyCare
The TimelyCare project evaluates whether a proactive primary care intervention aimed at improving coordination, continuity, and accessibility of care for individuals at risk of high care consumption can impact patient-experienced continuity, health outcomes, healthcare utilization, and costs.
Project information
Project manager
Anna Sandgren, Linnaeus University
Mirjam Ekstedt, Linnaeus University and Karolinska Institutet
Other project members
Ann-Therese Hedqvist, Linnaeus University and Region Kalmar County
Linda Ljungholm, Linnaeus University
Cecilia Fagerström, Linnaeus University and Forskningssektionen, Region Kalmar County
Mathias Karlsson, Region Kalmar County
Inna Feldman, Uppsala University
Participating organisations
Linnaeus University, Region Kalmar County with municipalities
Financier
Forte (Dnr 2024-01064)
Timetable
1 Jan 2025 - 31 Dec 2028
Subject
Caring Science (Department of Health and Caring Sciences, Faculty of Health and Life Sciences)
Research group
The ReAction Group
KKnowledge Environment
Linnaeus Knowledge Environment: Sustainable Health
More about the project
Healthcare services face major challenges in providing the right care at the right level for patients with complex health needs. A small proportion of the population consumes a disproportionate share of acute care resources, often due to a lack of continuity and coordination between levels of care. This can result in inefficient resource use and a care situation where patients risk not receiving the help they need in a timely manner. Based on exploratory studies and the region's analyses of where gaps arise, as well as evidence on effective practices, a model has emerged that is based on four integrated components (A-D, Table 1). These components aim to improve coordination, continuity, and accessibility for patients at risk of unplanned healthcare consumption. In this project, the model is called TimelyCare.
The four components of Timely Care:
(A) Coordination of care
Clear procedures for collaboration and information transfer between care providers
(B) Dedicated care contact
A designated care contact to strengthen continuity and safety.
(C) Proactive conversations / Serious Illness Conversations
Structured conversations to identify care needs and develop an individualized care and self-care plan.
(D) Fast track for urgent care needs
Tailored processes to get the right care at the right level in time.
Initially, we will map out which of TimelyCare's components have already been tested or implemented in the region's primary care. As part of the project, we intend to identify high-risk patients who are heavy users of healthcare using a prediction tool that considers both medical and sociodemographic factors (RUB/DESO), to provide targeted interventions to those who need them the most.
Co-creation design
The project uses a co-creation design based on collaboration between researchers at Linnaeus University and Uppsala University, in cooperation with Region Kalmar County and its municipalities. To ensure that TimelyCare is adapted to real needs, co-creation workshops are conducted where healthcare professionals, patient representatives, and decision-makers from primary and municipal care, and social services, as well as patients and relatives, identify challenges, develop solutions, and fine-tune and optimize working methods to implement the four components of TimelyCare in primary care. TimelyCare will be evaluated in a clinical intervention, where effects on health, continuity, accessibility, healthcare consumption and costs, are assessed in a cluster-randomized study. We use systemic frameworks for process evaluation and analyze patients' and staff's experiences of the primary care model.
Significance
The TimelyCare project tackles the societal need for optimized healthcare by focusing on the management of a vulnerable population with high healthcare usage in primary care. 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.
Providing the right care, at the right time, at the right level, will benefit both patients and the healthcare system.
The project is part of the research in the research group The ReAction Group and the Linnaeus Knowledge Environment: Sustainable Health.