Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review

Background: The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients. Method: A scoping review was conducted by searching electronic databases encompassing Medline, Embase, Scopus, and Web of Science. Three key concepts – 1) integrated care, 2) multimorbidity, and 3) Asian countries – were used to define searching strategies. Studies were included if an IC programme in Asia for multimorbidity was described or evaluated. Data extraction for IC components and elements was carried out by adopting the SELFIE framework. Results: This review yielded 1,112 articles, of which 156 remained after the title and abstract screening and 27 studies after the full-text screening – with 23 IC programmes identified from seven Asian countries. The top 5 mentioned IC components were service delivery (n = 23), workforce (n = 23), leadership and governance (n = 23), monitoring (n = 15), and environment (n = 14); whist financing (n = 9) was least mentioned. Compared to EU/US countries, technology and medical products (Asia: 40%, EU/US: 43%-100%) and multidisciplinary teams (Asia: 26%, EU/US: 50%–81%) were reported less in Asia. Most programmes involved more micro-level elements that coordinate services at the individual level (n = 20) than meso- and macro-level elements, and programmes generally incorporated horizontal and vertical integration (n = 14). Conclusion: In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned. There appears to be considerable scope for development. Highlights First scoping review to synthesise the key components and elements of integrated care programmes for multimorbidity in Asia. All programmes emphasized ‘distinctive service delivery’, ‘leadership’, and ‘workforce’ components. ‘Financing’ component was least mentioned in identified integrated care programmes.

person centred healthcare person centred service* patient-centred care patient-centred health care patient-centred healthcare patient-centred service* person-centred care person-centred health care person-centred healthcare person-centred service* comprehensive health care health planning care pathway* Critical path* medical and social healthcare medical and social care medical and social service* health and social care health and social service* Multimorbidity comorbidity Complex chronic patients frail elderly frailty frail elder* frail older adult* co-occur* co occur* health problem* health condition* chronic health problem* chronic disease* chronic condition* chronic illness* chronic disorder* complex need* complex condition* multiple health problem* multiple health condition* multiple chronic condition* multiple chronic disease* multiple chronic disorder* multiple chronic health problem* multiple chronic illness* multimorbid* multi-morbid* multi morbid* 1. ((integrat* or coordinat* or co-ordinat* or managed or cooperative or organi?ed or shar* or comprehensive or multidisciplinary or interdisciplinary or inter-disciplinary or crossdisciplinary or cross-disciplinary or transition* or transmural or "cross sectoral" or continuity or continuum or ((patient or patient-or person or person-or population or population-or people or people-) adj2 (cent?red or focus* or bas*))) adj4 (service* or care or "health care" or health-care or "patient care" or healthcare)).ti,ab.
2. ((integrat* or coordinat* or co-ordinat* or managed or cooperative or organi?ed or shar* or comprehensive or multidisciplinary or interdisciplinary or inter-disciplinary or crossdisciplinary or cross-disciplinary or transition* or transmural or "cross sectoral" or continuity or continuum or ((patient or patient-or person or person-or population or population-or people or people-) adj2 (cent?red or focus* or bas*))) adj4 ((service* or care or "health care" or health-care or "patient care" or healthcare) adj3 (system* or "provider system"))).ti,ab.
5. ((horizontal or vertical or virtual or organi?ational or professional or clinical or functional) adj3 integration).ti,ab.
29. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15  1. ((integrat* or coordinat* or co-ordinat* or managed or cooperative or organi?ed or shar* or comprehensive or multidisciplinary or interdisciplinary or inter-disciplinary or crossdisciplinary or cross-disciplinary or transition* or transmural or "cross sectoral" or continuity or continuum or ((patient or patient-or person or person-or population or population-or people or people-) adj2 (cent?red or focus* or bas*))) adj4 (service* or care or "health care" or health-care or "patient care" or healthcare)).ti,ab.
2. ((integrat* or coordinat* or co-ordinat* or managed or cooperative or organi?ed or shar* or comprehensive or multidisciplinary or interdisciplinary or inter-disciplinary or crossdisciplinary or cross-disciplinary or transition* or transmural or "cross sectoral" or continuity or continuum or ((patient or patient-or person or person-or population or population-or people or people-) adj2 (cent?red or focus* or bas*))) adj4 ((service* or care or "health care" or health-care or "patient care" or healthcare) adj3 (system* or "provider system"))).ti,ab.
5. ((horizontal or vertical or virtual or organi?ational or professional or clinical or functional) adj3 integration).ti,ab.
13. integrated health care system/ 14. long term care/ or case management/ or patient care planning/ 15. disease management/ 16. ("medical and social healthcare" or "medical and social care" or ("medical and social" adj2 service*) or "health and social care" or ("health and social" adj2 service*)).ti,ab.
21. (complex adj2 (need* or condition*)).ti,ab. (TITLE-ABS-KEY(((integrat* or coordinat* or co-ordinat* or managed or cooperative or organi?ed or shar* or comprehensive or multidisciplinary or interdisciplinary or inter-disciplinary or crossdisciplinary or cross-disciplinary or transition* or transmural or "cross sectoral" or continuity or continuum or ((patient or patient-or person or person-or population or population-or people or people-) chronic" W/1 (condition* OR disease* OR disorder* OR "health problem" OR "health problems" OR illness*)) OR ("multiple health" W/1 (problem* OR condition*)) OR (complex W/1 (condition* OR need*)) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") W/2 "chronic health" W/1 problem*) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") W/2 disorder*) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") W/2 health W/1 problem*) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") W/2 chronic W/1 (disease* OR condition* OR illness)) OR frailty OR (frail W/1 elder*) OR ((frail W /1 older) AND adult) OR ((frail W/1 older) AND adults))) AND NOT (DOCTYPE(ed or er or le or no or pr or re or sh)) AND ( CU=(china or chinese or japan* or korea* or taiwan or hong kong or singapore or thailand or vietnam or india* or iran or philippines or malaysia or Israel or asia*) or AD=(china or chinese or japan* or korea* or taiwan or hong kong or singapore or thailand or vietnam or india* or iran or philippines or malaysia or Israel or asia*) or TS=(china or chinese or japan* or korea* or taiwan or hong kong or singapore or thailand or vietnam or india* or iran or philippines or malaysia or Israel or asia*))

Web of Science
Updated to 2020.06.18 Searching resulst: 390 (comprehensive NEAR/1 "health care") or (comprehensive NEAR/1 healthcare) or (comprehensive NEAR/1 service*) or "case management" or case-management or "disease management") AND (TS=(multimorbid* OR (multi NEAR/1 morbid*) OR ("multiple chronic" or "complex chronic" NEAR/1 (condition* OR disease* OR disorder* OR "health problem" OR "health problems" OR illness*)) OR ("multiple health" NEAR/1 (problem* OR condition*)) OR (complex NEAR/1 (condition* OR need*)) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") NEAR/2 "chronic health" NEAR/1 problem*) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") NEAR/2 disorder*) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") NEAR/2 health NEAR/1 problem*) OR (( o-occur* OR "co occurring" OR "co occurrent" OR "co occurrence") NEAR/2 chronic NEAR/1 (disease* OR condition* OR illness)) OR frailty OR (frail NEAR/1 elder*) OR ((frail NEAR/1 older) AND adult) OR ((frail NEAR/1 older) AND adults))) NOT (DT= (Editorial Material OR Letter or News Item OR Note )) AND ( CU=(china or chinese or japan* or korea* or taiwan or hong kong or singapore or thailand or vietnam or india* or iran or philippines or malaysia or Israel or asia*) or AD=(china or chinese or japan* or korea* or taiwan or hong kong or singapore or thailand or vietnam or india* or iran or philippines or malaysia or Israel or asia*) or TS=(china or chinese or japan* or korea* or taiwan or hong kong or singapore or thailand or vietnam or india* or iran or philippines or malaysia or Israel or asia*))

Intervention: Case Management (n=130)
Services including:(a) home visit and telephone follow-up, (b) comprehensive geriatric assessment, (c) development of care plan, (d) coordinate health and social services, (e) monthly monitoring via IT system, (f) on-site and/or phone health and psychosocial counselling, (g) health educational programmes for patients and caregivers.

Control: usual medical care (n=130)
Conventional health and social services All participants had improved significantly in their levels of mood symptoms (p < .001) and informal support (p <.001).
Greater improvement in the level of continence, reduced the total number of unplanned hospital admissions, acute hospital bed days than those older persons in the control group.
The total savings over time in overall health care costs for the intervention group was still 93% more than that in the control group (U.S.$179,090 vs. U.S.$12,526).

Intervention: Targeted Case Management (n=45)
Services including: (a) regular monitoring of subjects' health status, (b) daily phone assistance , (c) home visits, (d) prescribing of community-based supportive services (i.e. community nursing services), (e) access to the case geriatrician by the case manager for medical support (telephone consultation, assessment of subjects in the outpatient department, and admission of subjects to the hospital).

Control: usual care (n=47)
Usual services of regular medical follow-up The common reasons for client-initiated telephone calls to NCMs and NCMs' interventions to these calls. Qualitative data yielded 9 major themes on which a sequential and dynamic process model of case management was conceptualized. Another 7 thematic descriptions on essential factors for the successful implementation of case management were configured in a dual-dimensional framework of staff and structural factors.

Wong, F., et al.(2011)
Effects of a healthsocial partnership transitional program on hospital readmission: A randomized controlled trial.

HK
To explore the outcomes of a health-social partnership program on post-discharge medical patients.
Quantitative method: randomized controlled trial 555 eligible patients recruited through an acute regional hospital home setting Intervention: Health-Social Transitional Care Management Programme (n=272) Service including: (a) pre-discharge phase: predischarge assessment, (b) post-discharge phase: first week -the NCM and TVs conducted a home visit together, second week -the NCM made a telephone follow-up call, third week -the TVs conducted a home visit in pairs, fourth week -the NCM made the final telephone follow-up call.

Control: usual discharge care (n=283)
The programme significantly reduced readmission at 4-weeks (study 4.0%, control 10.2%, p=0.005). The intention-to-treat result also showed a lower readmission rate with the study group but the result was not significant (study 11.5%, control 14.7%, p= 0.258). There was however significant improvement in quality of life, self-efficacy and satisfaction in the study group in both per-protocol and intention-totreat analyses.

Wong, F., et al.(2012)
Cost-effectiveness of a health-social partnership transitional program for post-discharge medical patients.

HK
To exam the costeffectiveness of a healthsocial partnership transitional care program for patients discharged from hospitals.
Quantitative method: randomized controlled trial 555 eligible patients recruited through an acute regional hospital home setting Intervention: Health-Social Transitional Care Management Programme (n=272) Service including: (a) home visit, (b) assessment in the domains of environment, physical, psychosocial and health-related behaviours and provide relevant intervention, (c) social support, (d) follow-up telephone calls, (e) further social assessment and interventions (daily living assistance, housing assistance, and counselling), (f) regular case reviews.
Utility values showed no difference between the control and study groups at baseline (p = 0.308). Utility values for the study group were significantly higher than in the control group at 28 (p < 0.001) and 84 days (p = 0.002). The study group also had a significantly higher QALYs gain (p < 0.001) over time at 28 and 84 days when compared with the control group.
The cost of readmission per subject within 28 and 84 days was lower in the study group than in the control group, and the differences were -HK$1505 (95% CI: -$2670, -$555) and -HK$3000 (−$5104, -$1211) for the two time periods respectively.
The intervention had an 89% chance of being cost-effective at the threshold of £20000/QALY.

Chow, S.K.Y.,et al.(2014)
A randomized controlled trial of a nurse-led case management programme for hospital-discharged older adults with comorbidities.

HK
To examine the effects of a nurse-led case management programme for hospital-discharged, older adults with comorbidities in Hong Kong.

Lee, K.H., et al.(2015)
Transitional care for the highest risk patients: findings of a randomised control study.

SG
To (i)

Control: usual medical care (n=421)
Services including: 2h education on-site course as the intervention group Proportion of patients with readmission within 60 and 90 days after intervention were not statistically significant between the intervention and control groups.
The rate of emergency department visits within 30, 60 and 90 days did not differ significantly between the intervention and control groups.
The intervention group reported a significantly higher level of satisfaction in all aspects of care surveyed. Similarly, there were no differences in the changes between the 2 groups for tobacco and alcohol use or other secondary outcomes. Activating appropriate community services to support the patient's care in the home setting), (b) draw up individualized patient-centred care plan, (c) telephone call reviews, (d) early physician reviews.

Control: none
Patients had a 51.6% and 52.8% reduction (p < 0.001) in hospital admissions in the three-month and six-month post enrolment, respectively. Similarly, a 47.1% and 48.2% reduction (p < 0.001) was observed for emergency department attendances in the three and six months post enrolment, respectively. The average difference in per patient hospital bed days in the pre-and post-enrolment periods were 12.05 days (p = 0.004) and 20.03 days (p=0.869) at the 3-month and 6-month periods, respectively.

Control: none
The pilot in Hangzhou was established as a Community Health Centre (CHC)-led delivery system based on cooperation agreement between CHCs and hospitals to deliver primary and specialty care together for patients with chronic diseases. An innovative learningfrom-practice mentorship system between specialists and general practitioners was also introduced to solve the poor capacity of general practitioners. The design of the pilot, its governance and organizational structure and human resources were enabling factors, which facilitated the integrated care reform. However, the main constraining factors were a lack of an integrated payment mechanism from health insurance and a lack of tailored information system to ensure its sustainability.

Goh, W.P., et al.(2018)
Acute medical unit: experience from a tertiary healthcare institution in Singapore.

SG
To describe the process, outcomes and learning points from AMU development initiative.

Intervention: Acute Medical Unit
Services including: (a) early internist-led assessment and management, (b) holistic management, (c) active re-triaging of patient, (d) inpatient treatment triggered, (e) allied health services, (f) clinical management support, (g) clinical services support.

Control: none
The internists provide holistic, patient-centric care with better overall ownership of the patients, improved efficiency and less fragmentation of care. The model of care also addresses conditions in which management plans can be expedited through having rapid access to investigations. It allows the specialty inpatient clinical teams to concentrate on the care of patients who truly need advanced tertiary care. It helps the hospital to rationalise resource allocation. It led to better containment and significantly reduced scatter of medical patients, especially to surgical wards. It serves as a good learning ground for residents and medical students with its remarkable case mix and exposure to acute medicine.

Jindal, D., et al.(2018)
Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in lowresource settings.

ID
To describe the steps and processes in the development and design of the mWellcare intervention.
Qualitative method: descriptive study N/A community setting

Intervention: mWellcare Programme -mHealthbased electronic decision support (EDS) system
Services including: for EDS system: (a) generate EDS recommendations for the management of diseases, (b) store electronic health records, (c) longterm monitoring and follow-up, (d) reminder message service for scheduled medication adherence and follow-up visits; for training: (e) centralized training on the clinical management guidelines to all physicians , (f) onsite training for NCD nurses in the management of hypertension, diabetes mellitus, depression, and tobacco and alcohol use, (g) training, onsite supervisor and support for nurses for orientation of the system.

Control: none
Lack of evidence-based, integrated, and systematic management of chronic conditions were major gaps identified. Experts in information technology, clinical fields, and public health professionals identified intervention components to address these gaps. Thereafter, clinical algorithm contextualized to primary care settings were prepared and the mWellcare intervention was developed. During the 2-month pilot, 631 patients diagnosed with hypertension and/ or diabetes were registered, with a follow-up rate of 36.2%. The major barrier was resistance to follow mWellcare recommended patient workflow, and to overcome it, we emphasized onsite training and orientation program to cover all health care team member in each CHC.

Intervention: The Reform of Integrated Service Delivery Network-Luohu Hospital Group (2015-2017)
Summary: (a) system integration: global budget, 6 administrative centres, 6 resources-sharing centres; (b) organisational integration: close hospital group (including 5 hospitals, 1 research institute, 6 health resource sharing centres, 6 administrative centres, 23 CHCs); (c) professional integration: multidisciplinary family doctor teams, specialists set up studio in CHCs, integrated care for the elderly; (d) functional integration: platform for two-way referrals, health Luohu APP and 4G mobile nursing; (e) normative integration: shared vision in the hospital group, build trust between residents and family doctor teams.

Control: none
The Luohu hospital group consists of five district hospitals, 23 community health stations and an institute of precision medicine. The group adopted a series of professional, organizational, system, functional and normative strategies for integrated care, which was provided for the residents of Luohu, especially for the elderly population and patients with chronic conditions.
According to a preliminary evaluation of the past two years, the Luohu model showed improvement in the structure and process towards integrated care. New preventive programs conducted in the hospital group resulted in changes of disease incidence. Residents were more satisfied with the Luohu model. However, spending exceeded the global budget for health insurance because of short-term increases in the demand for health care.

Intervention: Regional Health System
Summary: a network led by a major public hospital, working in close partnership with other healthcare providers (primary care providers, community hospitals, nursing homes, home care and day rehabilitation providers) and social care providers within the same geographical region.

Intervention: CARITAS Integrated Dementia Care
Services including: (a) regular case conference, (b) shared and transfer of care from hospital to primary and community care, (c) primary and community care providers trainings, (d) caregivers education and help-line .

Control: none
By considering the RHS and CARITAS as whole networks each comprising of interacting and adaptive components instead of separate entities within a bigger system, the CAS provided a new mind-set in surfacing issues associated to the implementation of these integrated care networks. In addition to important actors, systems, it informed understanding of relationships and dependencies between different parts of the networkrevealing the lack of homogeneity, conformity and difficulties in designing any optimal system in advance given the many moving parts.

TW
To estimate the effects of shifting from usual to integrated care and locates contextual factors that may distort programme implementation.

Quantitative method:
difference-in-difference design 168,043 patients in the panel database ambulatory setting community setting

Intervention: Family Doctor Plan
Services including: (a) multidisciplinary teams, (b) case management: health assessment, patient education and creation of health profiles, and (c) integrated care pathways: referrals, follow-ups and feedbacks, and transitional care management, a 24hour medical consultation telephone line, an operational plan for quality improvement.

Control: programme eligible patients who had not assigned
The programme reduced Continuity of Care Index (COCI) of provider continuity at the clinic level and continuity throughout the entire health care system, i.e. the clinic and hospital levels.
None of the incident rate ratios (IRRs) associated with the participation indicator was significant at the 5% level (95% confidence interval for the IRR: 0.

Control: none
Health-related quality of life (HRQoL) were positively associated to the primary care teams (PCT) exposure to training programmes of District Health Management Learning (DHML) and Contracting Unit of Primary Care (CUP) Leadership Training Programmes.
Family Practice Learning (FPL) was negatively associated with patient's HRQoL.
The duration of time spent working within the PCT was also slightly negatively associated with patient's HRQoL.

Ang, I.Y.H., et al.(2019)
Retrospective evaluation of healthcare utilisation and mortality of two post-discharge care programmes in Singapore.

SG
To evaluate the impact on healthcare utilisation frequencies and charges, and mortality of a programme for frequent hospital utilisers and a programme for patients requiring high acuity postdischarge care as part of an integrated healthcare model.

Control: none
The average hospitalisation expenses showed a decreasing trend and the actual compensation ratio increased significantly (p-value < 0.01).
Most of the indicators in the two counties performed well, and the effect of such policy was better in Funan County than in Dingyuan County.

CN
To examine the policymaking and implementation processes of the health reform in Luohu, including its policy environment and health care market context, the actors involved in the reform and their roles, and how the reform strategies were implemented to achieve integrated care.

Qualitative method:
semi-structured interviews and focus groups 36 informants, with government officials were purposely recruited and health workers were randomly selected ambulatory setting community setting

Intervention: The Reform of Integrated Service Delivery Network-Luohu Hospital Group (2015-2019)
Summary: (a) system integration: integrated health care with public health services (e.g., health education, free vaccination, etc.) and social services (e.g., home care for disabled elders, community care in collaboration with daycare centers, etc.); (b) organisational integration: merged resources of 5 district-level public hospitals and 23 public community health centers (CHCs), single legal entity (Luohu Hospital Group), 6 administrative centres and 6 supporting centres; (c) professional integration: motivated specialists to train providers and work part-time at CHCs, consolidated professional resources across hospitals; (d) clincial integration: a formal two-way referral system, timely decision support from specialists at hospitals to primary care doctors , encouraged providers to integrate clinical pathways; (e) functional integration: shared key support functions including shared information system; (f) normative integration: guided by a "health-centered" perspective and shared the goals of "less illness, fewer hospitalisations, less burden, and better care".

Control: none
The reform in Luohu took place in a competitive health care market, based on the comprehensive health reform in Shenzhen. Under the strong leadership of the district government, the reform adopted comprehensive strategies to strengthen primary care and care coordination, improve the quality and efficiency of health care delivery, and promote population health. The reform achieved a high level of organisational integration but was still in the process of fulfilling professional and clinical integration.

Leung TH, et al.(2020)
The effectiveness of an emergency physician-led frailty unit for the livingalone elderly: A pilot retrospective cohort study.

HK
To assess the effectiveness of frailty-care model in this locality.
Quantitative method: retrospective cohort study 190 eligible patients were recruited from Emergency Medicine Ward (EMW) of the hospital inpatient setting community setting Intervention: emergency physician-led frailtycare unit (n=150) Services including: (a) a mandatory and complete input of electronic Patient Assessment Form (PAF) by nursing staff, (b) a comprehensive enquiry of social background (e.g. safety bell, financial support and attendance to day care centre) (c) a mandatory bundled referral to the pre-discharge nursing service team, physiotherapist and occupational therapist upon admission, (d) daily ward round by a consultant and/or specialist emergency physician with nursing and allied health team to decide on a management plan, (e) a target of discharge within 72 h of admission.

Control: traditional general care (n=40)
Services including: (a) an optional or partial input of electronic Patient Assessment Form (PAF) by nursing staff, (b) a basic enquiry of social background would be conducted (e.g. activity of daily living and main carer) (c) referral to relevant nursing and allied health team individually as deemed necessary by the duty doctor, (d) daily ward round by a specialist or higher trainee in emergency medicine.
The length of stay in the acute hospital is significantly shortened (2.38 vs 3.27days, p=0.00018) than in the general group.
The transferral rate to a convalescent hospital was less in frailty group (21.3% vs 42.5%, p=0.00655).
There was no significant difference in terms of total (7.10 vs 10.99days, p=0.09638) and convalescent (22.09 vs 18.16days, p=0.48183) length of stay between frailty group and general group, respectively.
The transferral rate to convalescent hospital was less in the frailty group (21.3% vs 42.5%, p = 0.00655). Intervention: discharge services (n=31,247) Services including: (a) discharge planning , (b) rehabilitation discharge instruction to educate patients and their families on self-management in daily living, (c) instructions for community care at discharge to provide post discharge instructions (eg. medication safety at home, shared information with community healthcare workers), (d) coordination with long-term care (case needs assessment and long-term care plan based on medical, physical, or environmental problems).
In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001).
The odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001).
Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (PZ.001).
Nurjono M, et al.(2020) Shifting care from hospital to community, a strategy to integrate care in Singapore: process evaluation of implementation fidelity.

SG
To conduct process evaluation to examine the implementation fidelity of the National University Health System (NUHS) Regional Health System (RHS) program at providers, organizational, and system levels.

Control: none
Four out of six programme components were implemented with low level of fidelity, and 9112 suitable patients were referred to the program while 3032 (33.3%) declined to be enrolled. Moderating factors found to influence fidelity included: (i) complexity of program, (ii) evolving providers' responsiveness, (iii) facilitation through synergistic partnership, training of PCC providers by specialists and supportive structures: care coordinators, guiding protocols, shared electronic medical record and shared pharmacy, (iv) lack of organization reinforcement, and (v) mismatch between program goals, healthcare financing and providers' reimbursement.