An AI-enabled multimorbidity care service

为患有多种长期疾病（多发性硬化症）的患者提供预防性和积极主动的初级保健是NHS面临的主要挑战。主要疾病战略确定，25%的人口被诊断为六种慢性和长期疾病中的两种或两种以上，这些疾病占英格兰健康状况不佳和过早死亡的60%以上（卫生和社会保健部，2023年）。随着人口老龄化和生存率的提高，患有多发性硬化症的患者数量正在迅速增加，对有限的NHS资源造成了巨大压力。全科医生和初级保健网络（PCN）习惯于根据个人健康状况来规划护理服务。护理的黄金标准涉及“护理协调员”管理复杂的病例，但由于劳动力压力和繁重的工作量，他们很难管理多个单独的患者名单，并让患者进行预防性自我护理。几个令人困惑的系统性因素使其难以提供高质量的多器官衰竭护理：* 市场失灵-不明确的问责制和搭便车效应 * 双面问题-公共吸收必须与卫生服务能力相匹配 * 激励机制破碎-奖励单一条件输出而不是结果 * 紧迫性偏见-优先考虑紧急任务而不是重要任务这种模式对患者来说是灾难性的，他们感到不知所措，导航系统，并收到相互矛盾的建议和难以遵循的治疗方案，对动机，参与和结果产生负面影响。有效的多患者护理需要以患者为中心的方法，Appt是一家健康技术中小企业，与东伦敦的前瞻性PCN Network 6合作，开发一种全新的人工智能支持的多功能护理服务。这种方法的重点是使用先进的机器学习技术来了解每个患者的整体需求，并将这些需求映射到最合适的护理计划（与不同临床医生的一系列预约），这将确保早期诊断，自我管理和高质量的治疗，以管理他们的多重并发症的复杂性。

Providing preventive and proactive primary care for patients with multiple long-term conditions (multimorbidity) is a major challenge facing the NHS. The Major Conditions Strategy identified that 25% of the population are diagnosed two-or-more of the six chronic and long-term conditions that account for over 60% of ill-health and early death in England (Department for Health and Social Care, 2023). With an ageing population and improving survival rates, the number of patients living with multimorbidity is rapidly increasing, putting significant pressure on limited NHS resources.GP practices and Primary Care Networks (PCNs) are accustomed to planning care delivery around treating a person based on an individual health condition. The gold-standard of care involves 'Care Coordinators' managing complex cases, but due to workforce pressures and heavy workloads, they struggle to manage multiple, separate patient lists and engage patients in preventive self-care. Several confounding systemic factors make it difficult to deliver high-quality multimorbidity care :* Market failure - unclear accountability and free-rider effects* Two-sided problems - public uptake must match health service capacity* Broken incentives -rewarding single-condition outputs not outcomes* Urgency bias - prioritising urgent task over important onesThis paradigm isdisastrous for patients, who feel overwhelmed navigating the system and receive conflicting advice and hard-to-follow treatment regimens, negatively impacting motivation, engagement, and outcomes.Effective multimorbidity care requires a patient-centred approach, focused on prevention and patient empowerment.Appt is a health technology SME thathas partnered with Network 6, a forward-thinking PCN in East London, to develop a radical new, AI-enabled multimorbidity care service. This approach focuses on using advanced machine learning techniques to understand the holistic need of each patient and map that need to the most suitable care plan (a sequence of appointments with different clinicians) which will ensure early diagnosis, self-management, and high-quality treatment that manages the complexity of their multimorbidity.