The individual patient trajectory (iPT) for persons with multiple long-term conditions (LTCs) consists of multiple parallel care processes.
Patients with complex long-term needs experience multiple parallel care processes, which may have conflicting or competing goals, within their individual patient trajectory (iPT).
Whether an ICP enlists the system to provide direct assistance (e.g., activity prompting), retrieve care-related information, and coordinate care between AAL and multiple care partners, the decision and process by which ICPs entrust care to another party cannot be taken for granted.
Since integrated care delivery is characterized by overlapping care processes performed by multiple professionals, the complementary role of each health care professional and the interdependency among them are important features [ 23, 24].
A successful transition plan recognises transition as a multifaceted process that engages multiple care providers and accommodates a patient's condition, chronological age and developmental stage. 2 4 10 11 Many healthcare organisations, including hospitals, have developed transition programmes to help youth exit the paediatric system.
It is well known that CTMs are a potential response to the difficulties experienced by PCPs in caring for patients with multiple chronic diseases and may improve many care processes and health outcomes [ 9, 10, 27, 28].
After analysis, the low compliance was attributed to multiple factors including delays in sepsis recognition, insufficient awareness of sepsis resuscitation bundle and the complexity of the care processes.
4 11 21 22 Given that previous studies have found that many problems in care are related to general clinical care processes (including omissions of care) rather than specialist technical processes and that our sample would include many patients with multiple pathologies, we required reviewers with a generalist orientation.
Keith describes an end-of-life care process influenced at multiple levels.
