Breaking the Silos: How the PACE-It Model Improves Outcomes in Multimorbid Patients through Integrated Social and Clinical Care

The Challenge of Multimorbidity: Bridging Clinical and Social Gaps

The management of patients with multimorbidity—defined by the presence of two or more chronic conditions—is one of the most pressing challenges facing modern healthcare systems. In many developed nations, including Singapore, the traditional medical model often fails these individuals because their health is inextricably linked to psychosocial determinants that clinical settings are poorly equipped to address. Health and social care systems typically operate in silos, characterized by information asymmetry, fragmented service delivery, and a frequent duplication of efforts. This fragmentation often leads to poor clinical outcomes, especially for patients with complex care needs such as poorly controlled diabetes and significant psychosocial barriers.

Highlighting the PACE-It Success

• Significant Clinical Gains: Participants in the PACE-It program were more likely to achieve glycemic and lipid targets compared to those in usual care.
• Enhanced Patient Empowerment: The program led to higher levels of patient activation and significantly improved medication adherence.
• Technological Integration: A secure communication platform facilitated real-time collaboration between multidisciplinary health and social care providers.

Study Design and the PACE-It Intervention

The PACE-It (PrimAry CarE based Integrated community care Team) program was designed as a response to the fragmented care landscape. This pilot randomized controlled trial (RCT) was conducted at a public primary care organization in Singapore between December 2020 and February 2022. The study enrolled 41 individuals characterized by poorly controlled diabetes mellitus and complex psychosocial needs.The intervention centered on two primary pillars: a multidisciplinary team and a technology-assisted communication platform. The team comprised physicians, nurses, and allied health professionals working alongside social care workers. Unlike traditional referral models, this team utilized a secure platform to share insights, coordinate interventions, and ensure that both medical and social needs were addressed simultaneously. The control group received usual care, which typically involves standard clinical follow-ups and reactive social service referrals.

Key Findings: Driving Clinical and Patient-Reported Success

The 12-month evaluation of the PACE-It program revealed marked improvements across both objective clinical markers and subjective patient-reported outcomes.

Glycemic and Lipid Control

One of the most significant findings was the disparity in metabolic control. At the 12-month mark, 22.2% of individuals in the PACE-It group achieved an HbA1c of less than 7.5%, a stark contrast to the 9.1% observed in the usual care group. Furthermore, lipid management—a critical component of cardiovascular risk reduction in diabetic patients—showed substantial improvement. Approximately 80.0% of PACE-It participants reached an LDL cholesterol target of less than 2.6 mmol/L, compared to 57.1% in the control group.

Patient Activation and Medication Adherence

Beyond clinical metrics, the PACE-It program focused on empowering patients to manage their own health. Patient activation, measured by the Patient Activation Measure (PAM), saw a significant shift. In the intervention group, 43.8% of patients reached PAM levels 3 or 4 (indicating higher levels of knowledge, skill, and confidence for self-management), compared to only 23.3% in the usual care group. Medication adherence, assessed using the MARS-5 scale, also improved, with 9.5% of PACE-It patients achieving a score of 20 or higher, compared to 4.4% of those receiving usual care.

Collaborative Synergy

The discussion of these findings highlights that the benefits of PACE-It extended beyond the patients themselves. The co-development of the program fostered stronger professional relationships and improved collaboration between healthcare providers and social care workers. By breaking down the organizational silos, the program reduced the information asymmetry that often hampers care for complex patients.

Expert Commentary and Clinical Implications

The PACE-It model underscores a fundamental shift toward person-centered care. For clinicians, the takeaway is clear: medical interventions are often hindered by non-medical barriers. When social workers and clinical teams operate on the same communication frequency, the ‘social’ prescriptions (like housing assistance or financial aid) can be as vital as the ‘medical’ prescriptions.While the results are promising, it is important to note the small sample size (n=41) of this pilot RCT. Larger-scale studies are necessary to determine if these outcomes can be replicated across broader populations and to assess the long-term cost-effectiveness of the technology platform. However, the preliminary data suggest that the integration of technology does not replace the human element but rather acts as a catalyst for better multidisciplinary teamwork.

Conclusion

The PACE-It program provides a robust blueprint for integrating health and social care within a primary care setting. By combining a multidisciplinary team approach with a secure digital platform, the program successfully improved clinical outcomes for high-risk patients with diabetes and complex needs. As healthcare systems globally move toward value-based care, models like PACE-It will be essential in managing the growing burden of multimorbidity and ensuring that no patient falls through the gaps of a fragmented system.

References

1. Oka P, Wang ZS, Hu PL, Lee CE, Ng CJ. PACE-It: An Integrated Multidisciplinary Technology-Assisted Approach to Person-Centered Care for Individuals with Complex Care Needs. Journal of General Internal Medicine. 2026. PMID: 41811605.
2. World Health Organization. Integrated care models: an overview. 2016.
3. Hibbard JH, Greene J. What the evidence shows about patient activation: better outcomes and care experiences; fewer data on costs. Health Affairs. 2013.