title: Complex adaptive chronic care - typologies of patient journey: a case study.
abstract: BACKGROUND
  Complex adaptive chronic care (CACC) is a framework based upon complex adaptive systems' theory developed to address different stages in the patient journey in chronic illness. Simple, complicated, complex and chaotic phases are proposed as diagnostic types.
  
  
  OBJECTIVE
  To categorize phases of the patient journey and evaluate their utility as diagnostic typologies.
  
  
  METHODS
  A qualitative case study of two cohorts, identified as being at risk of avoidable hospitalization: 12 patients monitored to establish typologies, followed by 46 patients to validate the typologies. Patients were recruited from a general practitioner out-of-hours service. Self-rated health, medical and psychological health, social support, environmental concerns, medication adherence and health service use were monitored with phone calls made 3-5 times per week for an average of 4 weeks. Analysis techniques included frequency distributions, coding and categorization of patients' longitudinal data using a CACC framework.
  
  
  RESULTS
  Twelve and 46 patients, mean age 69 years, were monitored for average of 28 days in cohorts 1 and 2 respectively. Cohorts 1 and 2 patient journeys were categorized as being: stable complex 66.66% vs. 67.4%, unstable complex 25% vs. 26.08% and unstable complex chaotic 8.3% vs. 6.52% respectively. An average of 0.48, 0.75 and 2 interventions per person were provided in the stable, unstable and chaotic journeys. Instability was related to complex interactions between illness, social support, environment, as well as medication and medical care issues.
  
  
  CONCLUSIONS
  Longitudinal patient journeys encompass different phases with characteristic dynamics and are likely to require different interventions and strategies - thus being 'adaptive' to the changing complex dynamics of the patient's illness and care needs. CACC journey types provide a clinical tool for health professionals to focus time and care interventions in response to patterns of instability in multiple domains in chronic illness care.
authors.affiliation: National Digital Research Centre, Department of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland. carmelmarymartin@gmail.com
authors.forename: Carmel M
authors.initials: CM
authors.lastname: Martin
authors.forename: Deirdre
authors.initials: D
authors.lastname: Grady
authors.forename: Susan
authors.initials: S
authors.lastname: Deaconking
authors.forename: Catherine
authors.initials: C
authors.lastname: McMahon
authors.forename: Atieh
authors.initials: A
authors.lastname: Zarabzadeh
authors.forename: Brendan
authors.initials: B
authors.lastname: O'Shea
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease / Q000523:psychology / Q000628:therapy*; D015331:Cohort Studies; D004777:Environment; D005260:Female; D006296:Health Services / Q000706:statistics & numerical data; D006304:Health Status; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration* / Q000523:psychology; D008297:Male; D055118:Medication Adherence; D008603:Mental Health; D008875:Middle Aged; D036301:Qualitative Research; D057566:Self Report; D012944:Social Support