Meeting the Needs of a Complex Population: A Functional Health- and Patient-Centered Approach to Managing Multimorbidity
Bibliographic record
Abstract
Individuals with multimorbidity have complex care needs along with significant impacts to their functional health and quality of life. Recent evidence-based and experience-based explorations have revealed the importance of patient perspectives and functional health management in improving care delivery and health outcomes for individuals with multimorbidity. The impact of managing multimorbidity is evident at multiple levels of healthcare - the individual, the provider, and the system. Our local experience dealing with these challenges has led to the development of a functional health model that includes patient perspectives in care delivery within the Integrated Chronic Care Service (ICCS) of the health authority in Nova Scotia. In this paper, we present a discussion of the challenges, guiding models, and service-level transformations that have been integrated into care delivery at the ICCS to meet the healthcare needs of people with multiple health conditions. We describe our redesign strategies for care team planning, treatment approach, and patient inclusion.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".