How Can We Better Take Person-Centered Needs into Account? The Integrated Care Trajectory Approach and Intersectoral Collaboration in Primary Care to Support People Living with Diabetes
Bibliographic record
Abstract
Abstract Chronic diseases are the leading cause of mortality in industrialized countries and diabetes is one of the most important systemic chronic diseases. The consequences of diabetes on physical and mental health, and the economic impact on Quebec’s healthcare systems, are well documented. The organization of care by disease trajectory is a tool for optimizing the use of care and services in our healthcare system. However, the organization of care by disease trajectory does not always seem to correspond to people's needs and to the improvement of their health throughout their life course. Moreover, primary care and the community have a major role to play in the care of people with diabetes, as together they have the potential to better take into account the determinants of these people's health to optimize their follow-up. Indeed, living with a chronic disease is complex and requires a good understanding of the person's living environment. That's why collaboration between the healthcare sector and the community is a promising way of supporting people throughout their lives. The INMED-COMMUNITY trajectory has been developed and implemented since 2018 in a region near Montreal, Quebec, integrating a vision of care with the life course trajectory. This trajectory is promising and promotes an innovative approach to supporting people living with chronic diseases, described at the end of this chapter.
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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) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.001 | 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 | 0.001 |
| 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".