Clinical Research Directory

TimelyCare - A Proactive Primary Care Model: Delivering the Right Care at the Right Time for Individuals at Risk of High Care Consumption

Healthcare systems face persistent challenges in providing coordinated, proactive care for individuals with complex health needs, resulting in high vulnerability to fragmented care, acute clinical deterioration, and frequent emergency hospital admissions. TimelyCare is a proactive, multimodal primary care intervention designed to improve care continuity, optimize hospital-to-home transitions, and reduce unplanned acute healthcare dependency among high-risk individuals. This study evaluates the TimelyCare model using a pragmatic, stepped-wedge matched cluster-controlled trial (SW-CRT) with an open dynamic cohort across 12-15 primary healthcare centers in Region Kalmar, Sweden. The intervention targets individuals identified through an innovative combined risk algorithm integrating high morbidity (Resource Utilization Bands \[RUB\] levels 4-5) and sociodemographic vulnerability (Demographic Statistical Areas \[DeSO\]). The primary hypothesis is that exposure to the TimelyCare intervention will significantly reduce unplanned hospital admission rates over an 18-month follow-up period compared with usual care, while improving patient-experienced continuity, health-related quality of life, and healthcare cost-effectiveness.