Manage Complex Conditions Research Articles

An unusual occurrence: Treacher Collin syndrome with nasal dermoid cyst

Treacher-Collins syndrome (TCS), characterized by autosomal dominant inheritance, affects craniofacial development and presents with diverse clinical manifestations, including facial bone hypoplasia, ear malformations, and ocular abnormalities. The syndrome's association with nasal dermoid cysts is rare and poorly documented in the literature. We present a case report of a 10-year-old male with TCS who presented with a nasal dermoid cyst, a noteworthy and atypical finding within this patient population. The patient exhibited typical features of TCS, including facial asymmetry, malar and mandibular hypoplasia, and microtia. The diagnosis was confirmed through clinical evaluation and diagnostic imaging, which revealed additional anomalies such as conductive hearing loss and absence of the external auditory canal. Surgical excision of the nasal dermoid cyst was performed, utilizing the V-Y advancement glabellar flap technique for closure. This case underscores the importance of comprehensive multidisciplinary care in managing complex conditions like TCS, where treatment strategies must address both medical needs and cosmetic outcomes. Further exploration of rare associations like nasal dermoid cysts in TCS contributes to a broader understanding of the syndrome's phenotypic variability and informs optimal clinical management strategies.

Enhancing quality of care for older adults: The age‐friendly health system (4Ms framework) and the role of general medicine physicians as system‐based complexologists

AbstractThe aging population presents critical challenges to global healthcare systems, with Japan expected to have 35% of its population aged 65 or older by 2040. Older adults often experience multimorbidity, cognitive impairments, and physical frailties, increasing healthcare utilization and costs. Traditional medical approaches that focus on organ‐specific diagnoses are insufficient for addressing these multifaceted needs. The Age‐Friendly Health Systems (AFHS) framework, introduced in the U.S., offers a patient‐centered, value‐based approach to geriatric care, encompassing the "4Ms": Mentation, Mobility, Medication, and What Matters. These pillars prioritize cognitive health, physical function, appropriate medication use, and patient values. However, Japan has yet to implement this system widely. The integration of AFHS, with an additional focus on "Multicomplexity" (5Ms), aligns well with the core competencies of General and Family Medicine. This specialty is crucial in leading interdisciplinary efforts to enhance geriatric care, addressing fragmentation and variability in healthcare delivery. To successfully implement AFHS in Japan, general medicine physicians must be trained in managing complex conditions and coordinating care across specialties. This shift toward holistic, patientcentered care is essential for improving outcomes for older adults and reducing healthcare costs. Future research should focus on developing effective strategies for AFHS implementation and training healthcare teams for comprehensive care delivery.

Epilepsy care pathway: The Finnish model.

Integrated care pathways are essential for consistent, effective epilepsy care, offering equal access and quality regardless of socioeconomic status. They must align with the WHO Global Action Plan on Epilepsy, ensuring best practices and cost-effective management. We describe the Finnish national epilepsy care pathway, which includes multiple levels of care, from initial diagnosis to long-term care for all types of epilepsy, with a specific focus on rare and complex cases integrated with the European Reference Network (ERN) for Rare and Complex Epilepsies EpiCARE. In 2017, the Finnish government nominated Kuopio University Hospital to coordinate diagnostics and care for severe epilepsy in Finland. A national multidisciplinary consensus panel, including specialists from both adult and pediatric neurology departments across all five Finnish university hospitals and from the patient organization, was established. The resulting pathway was adopted into the current Finnish evidence-based current care guidelines for epilepsy. The Finnish epilepsy care pathway focuses on timely referrals, continuity of care and enhanced communication between healthcare providers at different levels of care. Patient involvement is assured with an individualized digital application offering secure online messaging, a seizure calendar, and remote visits. The pathway enhances virtual consultations and includes regular national diagnostic multidisciplinary meetings for severe epilepsies before selected cases are consulted in ERN EpiCARE meetings. This Finnish model for epilepsy care provides a streamlined, multidisciplinary approach to diagnosis and treatment and combines modern digital tools, data sharing, and peer support. This pathway can serve to model how integrated healthcare systems can effectively manage complex conditions. We describe the Finnish national epilepsy care pathway, which includes multiple levels of care, from initial diagnosis to long-term care for all types of epilepsy, with a specific focus on rare and complex cases integrated with the European Reference Network (ERN) for Rare and Complex Epilepsies EpiCARE. Finnish model for epilepsy care provides a streamlined, multidisciplinary approach to diagnosis and long-term treatment of epilepsy. The pathway enhances virtual consultations and includes national and European-level diagnostic multidisciplinary meetings for severe epilepsies. To improve outcomes, we emphasize the use of modern digital tools, data sharing, and peer support.

The role of machine learning in the improvement of physician-nurse relationships when the management of burn patients: A narrative review

In recent years, machine learning (ML) has emerged as a transformative technology in healthcare, providing significant advancements in patient care and management. Burn care, which necessitates comprehensive and coordinated efforts due to the severe and multifaceted nature of burn injuries, particularly benefits from ML's capabilities. This literature review investigates how ML enhances the collaboration between physicians and nurses in managing burn patients. In the present study, significant findings show that ML's predictive analytics can predict patient outcomes and complications, helping with proactive care strategies. ML-driven decision support systems offer real-time, evidence-based recommendations, ensuring consistent care approaches. In addition, ML-powered virtual simulations improve training and comprehension of roles, while advanced electronic health records (EHR) systems streamline documentation and information sharing. Continuous quality improvement is supported by ML's data-driven insights, leading to improved patient monitoring and management. Ultimately, integrating ML in burn care significantly improves physician-nurse collaboration, resulting in better patient outcomes. This includes reduced infection rates and shorter hospital stays. This highlights the vital role of ML in transforming healthcare delivery and professional collaboration in managing complex conditions like burn injuries.

Patients’ perceptions of community pharmacists’ role: A cross-sectional study in Lebanon

Introduction Recognizing, fostering, and maintaining a favorable public image is crucial for developing strong connections between patients and pharmacists, ultimately enhancing the pharmacist’s influence on healthcare results. Consequently, this research seeks to evaluate how the community perceives the role of pharmacists in Lebanon. Methods A cross-sectional study was conducted among the Lebanese residents over 2 months. One-way analysis of variance assessed the relationship between the perception score and the general characteristics of the study sample. A multivariate analysis was performed using linear regression models to evaluate the combined effect of predictors on the perception score. Results The study comprised exclusively Lebanese participants, with a slightly higher proportion of males (53.4%) than females (46.6%) and a diverse age distribution, ranging from 18 to 65 years old, with 9.1% being 65 years or older. After adjusting for covariates, females scored 0.25 points lower than males (CI (−0.65, 0.15); p = .217), while individuals aged 40–49 and 50–65 had perception scores of 0.18 and 0.55 points lower than those aged 18–29, respectively (CI (−0.83, 0.48); p = .595 and CI (−1.29, 0.20); p = .153, respectively). Participants from Nabatiyeh had a perception score increase of 0.82 compared to those in Beirut (CI (0.15–1.49); p < .017), and those working in non-medical fields scored 0.90 points lower than others (CI (−1.49, −0.32); p = .002). Individuals with at least one comorbidity scored 0.83 points lower (CI (−1.44, −0.21); p = .008), while patients with public insurance and those with a treatment duration of 6 months had perception scores 0.57 and 0.66 points lower, respectively, compared to their counterparts (CI (−1.12, −0.03); p = .039 and CI (−1.29, −0.03); p = .040). Conclusion Findings stress the significance of tailored healthcare and consistent patient-pharmacist relationships, especially for managing complex conditions, underscoring the importance of understanding these dynamics to bolster trust and appreciation for community pharmacists in Lebanon.

Practical Aspects of Providing Intradialytic Parenteral Nutrition for Hemodialysis Patients in Indonesia

This paper conducts a comprehensive literature review on the administration of intradialytic parenteral nutrition (IDPN) for patients undergoing hemodialysis (HD) in Indonesia. The objective is to assess the current status and challenges associated with IDPN in the country and propose potential strategies for enhancement. The review, encompassing articles published between 2013 and 2023 from databases such as PubMed, Scopus, and Google Scholar, exposes significant risks and the prevalence of malnutrition, particularly protein-energy wasting (PEW), among patients undergoing HD. This patient cohort often necessitates nutritional therapy, and IDPN emerges as a viable option for both prevention and definitive treatment. However, detailed data on malnutrition among HD patients in Indonesia are limited. Challenges include a shortage of nutrition experts in kidney care, low patient adherence to dietary advice, and the inability of Indonesian hospitals to provide IDPN to malnourished hemodialysis patients. The non-uniform cost coverage by the National Health Insurance further complicates matters, despite consumable costs for HD being uniform across all hospitals. The payment system by BPJS does not accommodate the provision of parenteral IDPN with varying prices, as listed in the e-catalog by the national public procurement agency. To offer IDPN to patients, hospitals must achieve cost-efficiency within their HD units, or they risk financial losses. Currently, IDPN is exclusively administered to HD patients with acute conditions in an inpatient setting. A recommendation for policymakers is to explore the adoption of distinct tariffs for HD patients undergoing outpatient care, particularly those managing complex conditions such as PEW. This approach can contribute to improved nutritional support for hemodialysis patients in Indonesia.

Specialty preference for cardiovascular prevention practice in the Southeast US and role of a preventive cardiologist.

Cardiovascular disease (CVD) prevention is practiced concurrently by providers from several specialties. Our goal was to understand providers' preference of specialties in CVD prevention practice and the role of preventive cardiologists. Between 11 October 2021 and 1 March 2022, we surveyed providers from internal medicine, family medicine, endocrinology, and cardiology specialties to examine their preference of specialties in managing various domains of CVD prevention. We examined categorical variables using Chi square test and continuous variables using t or analysis of variance test. Of 956 invitees, 263 from 21 health systems and 9 states responded. Majority of respondents were women (54.5%), practicing physicians (72.5%), specializing in cardiology (43.6%), and working at academic centers (51.3%). Respondents favored all specialties to prescribe statins (43.2%), ezetimibe (37.8%), sodium-glucose cotransporter-2 (SGLT2) inhibitors (30.5%), and aspirin in primary prevention (36.3%). Only 7.9% and 9.5% selected cardiologists and preventive cardiologists, respectively, to prescribe SGLT2 inhibitors. Most preferred specialists (i.e. cardiology and endocrinology) to manage advanced lipid disorders, refractory hypertension, and premature coronary heart disease. The most common conditions selected for preventive cardiologists to manage were genetic lipid disorders (17%), cardiovascular risk assessment (15%), dyslipidemia (13%), and refractory/resistant hypertension (12%). For CVD prevention practice, providers favored all specialties to manage common conditions, specialists to manage complex conditions, and preventive cardiologists to manage advanced lipid disorders. Cardiologists were least preferred to prescribe SGLT2 inhibitor. Future research should explore reasons for selected CVD prevention practice preferences to optimize care coordination and for effective use of limited expertise.

Barriers to the Development of Clinical Reasoning Skills among Coronary Care Nurses: A Qualitative Study.

Clinical Reasoning (CR) is a main professional competency for nurses which have significant contribution to sound clinical performance in critical clinical conditions. Nonetheless, evidence shows that nurses do not have the necessary competencies and thinking skills for managing complex conditions in critical care units. This study aimed at exploring the barriers to the development of CR skills among coronary care nurses. Using conventional content analysis, this qualitative study was conducted in 2020 in the Coronary Care Unit (CCU) of Heshmat Subspecialty Heart Center in Rasht, Iran. Participants were 15 nurses, head nurses, nursing supervisors, nursing managers, and nursing instructors. Data were collected using semi-structured interviews and were analyzed using conventional content analysis. The four main categories of the barriers to CR skill development among nurses were limited professional development, inefficient educational program, ineffective professional interactions, and limited professional self-efficacy. There are different personal, educational, professional, and interprofessional barriers to the development of CR skills among CCU nurses. Study findings can be used to develop effective strategies for supporting and developing nurses' CR skills.

A pre-post study investigating the effectiveness of functional neurological disorder (FND) training to increase healthcare staff’s knowledge, and confidence in FND management

Educational interventions aimed at improving healthcare professionals’ (HCPs) knowledge and confidence in managing complex conditions are widely recommended. However, there is limited evidence regarding the impacts of such interventions on HCP confidence and knowledge in relation to the management of Functional Neurological Disorder (FND). This investigation aimed to ascertain whether a two-hour FND training session, delivered online in group format, improved HCP confidence and knowledge in FND management, using a pre-post repeated measures design. Responses from 25 HCPs from community-based rehabilitation services at Whittington Health NHS Trust were included in the analysis. The findings indicated significant improvements in participant confidence and knowledge scores following training, suggesting the potential value of accessible low-cost training within the NHS. Future studies could adopt a randomised controlled trial design to reliably determine the effectiveness of delivering the training.

Innovations in pediatric ophthalmology and strabismus: diagnosis and treatment

To familiarize pediatric ophthalmologists and strabismus surgeons with new and innovative diagnostic and treatment tehcniques used to manage complex conditions typically associated with high levels of morbidity.

Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity

BackgroundNursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers.MethodsThis is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described.ResultsFindings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable.ConclusionsImproved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

Origins, motives, and challenges in Western–Chinese research collaborations amid recent geopolitical tensions: findings from Swedish–Chinese research collaborations

Until recently, modern science had been dominated by a handful of Western countries. However, since the turn of the millennium, the global science landscape has undergone dramatic changes. The number of nations where a significant proportion of research done is of high international standard has now increased considerably. China particularly stands out and is today one of the leading science nations in the world. Overall, Chinese research collaborations with countries in the Western world exemplify the general trend towards increasing complexity in the global research landscape. It has gradually become obvious that differences between institutional settings need to be managed more systematically to promote cross-border research cooperation for shared benefits, from individual to institutional levels. An informed discussion of managing complex conditions necessitates an understanding of the relationship-level dynamics of research collaborations. In order to identify what aspects of international research collaborations are the most pertinent to systematically manage at individual and institutional levels, this paper investigates projects in a bilateral Swedish–Chinese funding program. The paper finds that the majority of collaborations funded had yielded positive impact in terms of publications, strengthened research capacity in research groups, and resource accumulation. The challenges found in the collaborations are related to needs such as improving transparency, ethical concerns, and imbalances in reciprocity.

Artificial intelligence in dentistry, orthodontics and Orthognathic surgery: A literature review.

Artificial intelligence is the ability of machines to work like humans. The concept initially began with the advent of mathematical models which gave calculated outputs based on inputs fed into the system. This was later modified with the introduction of various algorithms which can either give output based on overall data analysis or by selection of information within previous data. It is steadily becoming a favoured mode of treatment due to its efficiency and ability to manage complex conditions in all specialities. In dentistry, artificial intelligence has also popularised over the past few decades. They have been found useful for diagnosis in restorative dentistry, oral pathology and oral surgery. In orthodontics, they have been utilised for diagnosis, assessment of treatment needs, cephalometrics, treatment planning and orthognathic surgeries etc. The current literature review was planned to highlight the uses of artificial intelligence in dentistry, specifically in orthodontics and orthognathic surgery.

The Role of Artificial Intelligence in Managing Multimorbidity and Cancer.

Traditional healthcare paradigms rely on the disease-centered approach aiming at reducing human nature by discovering specific drivers and biomarkers that cause the advent and progression of diseases. This reductive approach is not always suitable to understand and manage complex conditions, such as multimorbidity and cancer. Multimorbidity requires considering heterogeneous data to tailor preventing and targeting interventions. Personalized Medicine represents an innovative approach to address the care needs of multimorbid patients considering relevant patient characteristics, such as lifestyle and individual preferences, in opposition to the more traditional “one-size-fits-all” strategy focused on interventions designed at the population level. Integration of omic (e.g., genomics) and non-strictly medical (e.g., lifestyle, the exposome) data is necessary to understand patients’ complexity. Artificial Intelligence can help integrate and manage heterogeneous data through advanced machine learning and bioinformatics algorithms to define the best treatment for each patient with multimorbidity and cancer. The experience of an Italian research hospital, leader in the field of oncology, may help to understand the multifaceted issue of managing multimorbidity and cancer in the framework of Personalized Medicine.

Yoga in major depressive disorder: molecular mechanisms and clinical utility.

Major depressive disorder (MDD) is a mind-body disorder. Cellular aging has been implicated in the pathogenesis of MDD with the altered mind-body communication markers like stress response, immune response, nutrition sensing, and a range of other regulatory feedback systems. In this age of super specializations, one specific target and interventions (preferably a drug) on it are being rigorously sought by the health care community and industry, but have failed in it in the last fifty years in spite of advances in technology. Since, depression is a complex disorder associated with increased incidence of other complex disorders, it must be treated by an integrated holistic approach that can address the complexity of MDD. Interventions targeting accelerated biological aging to increase cellular health in whole body have potential to manage complex conditions like MDD and its overlapping symptoms and comorbidities. Yoga has the potential to be the nexus between, clinical management of MDD and other lifestyle diseases.

Abstract 14114: Sodium-glucose Cotransporter-2 Inhibitors Benefit Cardiac Diastolic Function

Introduction: Sodium-glucose Cotransporter-2 (SGLT-2) inhibitors are drugs with profound interest because of their beneficial effect on multiple organ systems, including the cardiovascular and renal systems. Their interplay with these systems could prove beneficial in managing complex conditions like heart failure with preserved ejection fraction. We sought to compare cardiac diastolic function in patients on SGLT-2 inhibitors with those on metformin. Methods: Data were collected retrospectively after approval from our institutional review board. The study group included patients on SGLT-2 inhibitors (n=75), and the control group had patients on metformin (n=82), primarily for diabetes mellitus. Patients with ejection fraction less than 50% were excluded from the study. Data collected included age, systolic blood pressure (SBP), left ventricular (LV) ejection fraction, LV and left atrial dimensions, and diastolic parameters. Mean values, along with standard deviation, were calculated. Multivariate regression analysis for diastolic function was performed while adjusting for confounders, including age, body mass index, and SBP. Results: Study group showed better diastolic function as evidenced by significantly higher e’ medial (6.8 v/s 6.16 cm/s; p = 0.03) and e’ lateral (9.8 v/s 7.9 cm/s; p=0.008) when compared to the control group. E/e’, a marker of pulmonary capillary wedge pressure, was lower in the study group (12.87 v/s 14.36; p=0.08); however, it did not reach statistical significance. LA volume index was significantly lower in the study group, suggestive of favorable hemodynamic status (26.5 v/s 29.6 mL/m 2 ; p=0.03). SBP was significantly lower in the study group (127 v/s 135 mm Hg; p=0.01). Multivariate regression model demonstrated SBP as a significant confounder that contributed to e’ (average) difference between the two groups. Conclusions: SGLT-2 inhibitors favored better diastolic measurements when compared with metformin alone. The mechanism may be attributed to its BP-lowering effect. A larger prospective study is required to determine the role of SGLT-2 inhibitors.

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review.

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Project ECHO: Building capacity to manage complex conditions in rural, remote and underserved areas.

There is a need to bring specialized medical expertise to rural and remote areas. Project ECHO offers a method to move knowledge from specialists in academic centres using videoconference, case-base learning, and best-practices knowledge sharing. Ontario has implemented ECHO since 2014 and has demonstrated favourable outcomes among primary care clinicians.

Staged distraction osteogenesis followed by arthrodesis using internal fixation as a form of surgical treatment for complex conditions of the ankle.

The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique. Between 2008 and 2014, distraction osteogenesis followed by arthrodesis using internal fixation was performed in 12 patients with complex conditions of the ankle due to trauma or infection. There were eight men and four women: their mean age was 35 years (23 to 51) at the time of surgery. Bone healing and functional recovery were evaluated according to the criteria described by Paley. Function was assessed using the ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS). A solid fusion of the ankle and eradication of infection was achieved in all patients. A mean lengthening of 6.1 cm (2.5 to 14) was achieved at a mean follow-up of 25.2 months (14 to 37). The mean external fixation index (EFI) was 42 days/cm (33.3 to 58). The function was judged to be excellent in six patients and good in six patients. Bone results were graded as excellent in ten patients and good in two patients. The mean AOFAS score was 37.3 (5 to 77) preoperatively and 75.3 (61 to 82) at the final follow-up. Minor complications, which were treated conservatively, included pain, pin-tract infection, loosening of wires, and midfoot stiffness. Major complications, which were treated surgically included grade V pin-tract infection with inflammation and osteolysis, poor consolidation of the regenerate bone, and soft-tissue invagination. The reoperations required to treat the major complications included the exchange of pins and wires, bone grafting and invagination split surgery. The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early, and a reduced EFI without infection or wound dehiscence. Cite this article: Bone Joint J 2018;100-B:755-60.

Irish Integrated Care Programme for Chronic Disease - Supporting General Practice

Introduction: Ireland has an ageing population and challenges in caring for people with chronic disease. The prevalence of major chronic diseases of heart disease, diabetes, respiratory disease will increase by 20% by 2022. Since 2008 Irish Health Services suffered severe austerity measures with funding reduction of 24%. Ireland has no organised system of chronic disease management in Primary Care. GPs not rewarded for active management, many patients rely on hospital OPD management . Description of policy context and objective: Government policy has mandated the Integrated Care Programme for Chronic Disease (ICP CD). The objective is to “provide a full spectrum of care including prevention, early detection, management in Primary Care and appropriate Secondary Care services”. Care is to be delivered at “the lowest level of appropriate complexity”. A new GP contract for chronic disease management is being developed. The contract will reward GPs for proactive health promotion, risk assessment and early detection of chronic disease, scheduled proactive management according to national clinical guidelines. ICP CD is developing and piloting a suite of supports to GPs. Targeted population: Population targeted is the 700,000 people who suffer from significant heart disease, diabetes or respiratory disease. Stakeholders are patients, GPs, practice nurses, community specialist nurses, hospital specialist nurses and hospital specialists. Community services developed for 50,000 population networks. Highlights: Programme innovative initiatives; - Projects in diabetes, respiratory disease and heart failure; clinical nurse specialists and physiotherapists to work between clusters of General Practices (50,000 population) and local hospital specialist providing improved diagnosis, knowledge transfer to GPs, support for managing complex patients and rapid access to specialist opinion. - Community podiatrists and dieticians to support community models of care. (1 per 50,000) - National Framework and training for implementing risk factor assessment and brief intervention “Make Every Contact Count”. - National Framework, training and local sign posting for Self Management Supports. - Virtual Clinics between hospital specialists and GPs for case presentation, support of management and knowledge transfer. - Rapid specialist email opinion. - Specialist clinic in GP settings (under development). Virtual clinic operational; demonstrated 85% reduction in OPD referrals. Recruitment of clinical nurse specialists, physiotherapists, podiatrists, dieticians rapidly ramped up. New job descriptions and KPIs agreed nationally. Blueprints for the new contract developed. Transferability: To enable General Practitioners to manage complex conditions requires systematic supports to be developed. The initiatives outlined are replicated in many parts of the world and have demonstrated the ability to transfer when adapted to local health systems. Conclusions: Key findings, lessons learned; - Clinical leadership and national policy critical. - Demonstrate the effectiveness but rapidly scale up to population. - Partnership with General Practitioners, Royal Colleges essential. - Stakeholders consultation essential. - GPs, practice nurses eager to manage patients in Primary Care if supported. - Significant changes in practice for GPs require contractual changes and financial alignment.