Acute Complex Care Model: An organizational approach for the medical care of hospitalized acute complex patients

Published:September 10, 2015DOI:


      • AICPPs require a specialist of complexity, the internist.
      • ACCM defines AICPPs' characteristics, physicians' skills, pathways, and timing.
      • ACCM represents the hospital counterpart of the Chronic Care Model.
      • Alliance with decision makers is proposed to allocate adequate resources for AICPPs.



      Chronic diseases are the major cause of death (59%) and disability worldwide, representing 46% of global disease burden. According to the Future Hospital Commission of the Royal College of Physicians, Medical Division (MD) will be responsible for all hospital medical services, from emergency to specialist wards. The Hospital Acute Care Hub will bring together the clinical areas of the MD that focus on the management of acute medical patients. The Chronic Care Model (CCM) places the patient at the center of the care system enhancing the community's social and health support, pathways and structures to keep chronic, frail, poly-pathological people at home or out of the hospital. The management of such patients in the hospital still needs to be solved. Hereby, we propose an innovative model for the management of the hospital's acute complex patients, which is the hospital counterpart of the CCM.

      Acute Complex Care Model (ACCM)

      The target population are acutely ill complex and poly-pathological patients (AICPPs), admitted to hospital and requiring high technology resources. The mission is to improve the management of medical admissions through pre-defined intra-hospital tracks and a global, multidisciplinary, patient-centered approach. The ACCM leader is an internal medicine specialist (IMS) who summarizes health problems, establishes priorities, and restores health balance in AICPPs.


      The epidemiological transition leading to a progressive increase in “chronically unstable” and complex patients needing frequent hospital treatment, inevitably enhances the role of hospital IMS in the coordination and delivery of care. ACCM represents a practical response to this epochal change of roles.

      Graphical abstract


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        • World Health Organization
        Global Strategy on Diet, Physical Activity, and Health.
        (accessed on April 24, 2015)
      1. (accessed on April 24, 2015).
      2. Better non-communicable disease outcomes: challenges and opportunities for health systems.
        Assessment Guide. WHO Regional Office for Europe, 2014
      3. Strengthening people-centred health services delivery in the WHO European Region: concept note.
        WHO Europe, 2014
        • Porcel J.M.
        • Casademont J.
        • Conthe P.
        • Pinilla B.
        • Pujol R.
        • Garcia-Alegria J.
        Core competencies in internal medicine.
        Eur J Intern Med. 2012; 23: 338-341
        • Scotti E.
        • Pietrantonio F.
        The hospital Internal Medicine specialist today: a literature review and strength, weaknesses, opportunity, threats (SWOT) analysis to develop a working proposal.
        Ital J Med. 2013; 7: 278-286
        • La Regina M.
        • Orlandini F.
        On behalf of the Ligurian FADOI group. Census of Ligurian Internal Medicine Wards of non-teaching hospitals.
        Ital J Med. 2014; 8: 246-252
      4. (accessed on April 25, 2015)
        • Cranston M.
        • Semple C.
        • Duckitt R.
        • Vardi M.
        • Lindgren S.
        • Davidson C.
        • et al.
        For the European Board of Internal Medicine Competencies Working Group. The practice of internal medicine in Europe: organisation, clinical conditions and procedures.
        Eur J Intern Med. 2013; 24: 627-632
        • Flanders S.A.
        • Wachter R.M.
        Hospitalists: the new model of inpatient medical care in the United States.
        Eur J Intern Med. 2003; 14: 65-70
        • Kellett J.
        Acute hospital medicine—a new sub-speciality or internal medicine re-born?.
        Eur J Intern Med. 2011; 22: 334-338
        • Wachter R.M.
        • Goldman L.
        The emerging role of “hospitalists” in the American health care system.
        N Engl J Med. 1996; 335: 514-517
        • Nardi R.
        • Berti F.
        • Fabbri L.M.
        • et al.
        Towards a sustainable and wise healthcare approach: potential contributions from hospital internal medicine departments to reduce inappropriate medical spending.
        Ital J Med. 2013; 7: 65-81
      5. (accessed on April 25, 2015)
        • Palsson R.
        • Kellet J.
        • Lindgren S.
        • Merino Jamie
        • Semple C.
        • Sereni D.
        For the EFIM/UEMS working group on competencies in internal medicine in Europe, core competencies of the European internist: a discussion paper.
        Eur J Intern Med. 2007; 18: 104-108
        • Pugh D.
        • Hamstra S.J.
        • Wood T.J.
        • Humphrey-Murto S.
        • Touchie C.
        • Yudkowsky R.
        • et al.
        A procedural skills OSCE: assessing technical and non-technical skills of internal medicine residents.
        Adv Health Sci Educ. March 2015; 20: 85-100
        • Specialty training curriculum for Acute Internal Medicine
        Joint Royal Colleges of Physicians Training Board.
        (accessed on August 16, 2015)
        • Beltrán L.M.
        • García-Casasola G.
        • members of the Group of Clinical Ultrasound of the Spanish Society of Internal Medicine
        Ultrasonography managed by internists: the stethoscope of 21st century?.
        Rev Clin Esp (Barc). 2014 Apr; 214: 155-160
        • Arienti V.
        • Camaggi V.
        Clinical applications of bedside ultrasonography in internal and emergency medicine.
        Intern Emerg Med. 2011 Jun; 6: 195-201
        • Moore C.L.
        • Copel J.A.
        Point of care ultrasonography.
        N Engl J Med. 2011 Feb 24; 364: 749-757
        • Solomon S.D.
        • Saldana F.
        Point-of-care ultrasound in medical education–stop listening and look.
        N Engl J Med. 2014 Mar 20; 370: 1083-1085
        • Wachter R.M.
        • Goldman L.
        The emerging role of “hospitalists” in the American health care system.
        N Engl J Med. 1996; 335: 514-517
        • Kuo Y.F.
        • Sharma G.
        • Freeman J.L.
        • Goodwin J.S.
        Growth in the care of older patients by hospitalists in the United States.
        N Engl J Med. 2009; 360: 1102-1112
        • Meltzer D.O.
        • Chung J.W.
        U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists.
        J Gen Intern Med. 2010; 25: 453-459
        • Lindenauer P.K.
        • Rothberg M.B.
        • Pekow P.S.
        • Kenwood C.
        • Benjamin E.M.
        • Auerbach A.D.
        Outcomes of care by hospitalists, general internists, and family physicians.
        N Engl J Med. 2007; 357: 2589-2600
        • Rachoin J.S.
        • Skaf J.
        • Cerceo E.
        • et al.
        The impact of hospitalists on length of stay and costs: systematic review and meta-analysis.
        Am J Manag Care. 2012; 18: e23-e30
        • Seiler A.
        • Visintainer P.
        • Brzostek R.
        • Ehresman M.
        • Benjamin E.
        • Whitcomb W.
        • et al.
        Patient satisfaction with hospital care provided by hospitalists and primary care physicians.
        J Hosp Med. 2012 Feb; 7: 131-136
      6. Future Hospital: caring for medical patients.
        A Report from the Future Hospital Commission to the Royal College of Physician. 28. September 2013
        • National Early Warning Score (NEWS)
        Standardising the assessment of acute-illness severity in the NHS. Report of a working party. Royal College of Physicians.
        (Review date: 2015) ([accessed on August 16, 2015])
        • Capuzzo M.
        • Moreno R.P.
        • Le Gall J.R.
        Outcome prediction in critical care: the Simplified Acute Physiology Score models.
        Curr Opin Crit Care. 2008 Oct; 14: 485-490
        • Halm E.A.
        • Fine M.J.
        • Kapoor W.N.
        • et al.
        Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia.
        Arch Int Med. 2002; 162: 1278-1284
        • Bora D.P.
        • Melot C.
        • Ferreira F.L.
        • Ba V.N.
        • Vincent J.L.
        The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction.
        Intensive Care Med. 2002; 28: 1619-1624
        • Rogers J.
        • Fuller H.D.
        Use of daily Acute Physiology and Chronic Health Evaluation (APACHE) II scores to predict individual patient survival rate.
        Crit Care Med. 1994; 22: 1402-1405
        • Le Gall J.R.
        • Lemeshow S.
        • Saulnier F.
        A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.
        JAMA. 1993 Dec 22-29; 270: 2957-2963
        • Moreno R.P.
        • Metnitz P.G.H.
        • Almeida E.
        • Jordan B.
        • Bauer P.
        • Abizanda Campos R.
        • et al.
        on behalf of the SAPS 3 Investigators. SAPS 3—From evaluation of the patient to evaluation of the intensive care unit.Part 2: Development of a prognostic model for hospital mortality at ICU admission.
        Intensive Care Med. 2005; 31: 1345-1355
        • Bartolomei C.
        • Cei M.
        The allocation of patients in an intensity-of-care based internal medicine ward: the ADOIT Tri-Co (Triage in the Corridor) study.
        Ital J Med. 2007; 2: 31-39
        • Robb G.
        • Seddon M.
        A multi-faceted approach to the physiologically unstable patient.
        Qual Saf Health Care. 2010; 19: e47
        • Kellet J.
        • Kim A.
        Validation of an abbreviated Vitalpac™ Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian regional hospital.
        Resuscitation. 2012; 83: 297-302
        • Prytherch D.
        • et al.
        ViEWS-towards a national Early Warning Score for detecting adult inpatient deterioration.
        Resuscitation. 2010; 81: 932-937
        • Capuzzo M.
        • Volta C.A.
        • Tassinati Moreno R.P.
        • Valentin A.
        • Guidet B.
        • Iapichino G.
        • Martin G.
        • Perneger T.
        • Combescure C.
        • Poncet A.
        • Rhodes A.
        • on behalf of the Working Group on Health Economics of the European Society of Intensive Care Medicine Critical Care
        • Passalia C.
        • Mazzacurati G.
        • Marinaro A.
        • Piredda S.
        • Corsini F.
        • Pacetti E.
        • et al.
        MEWS, RAY score and resources consumptions.
        Ital J Med. 2014; 8 ([29]): 97-98
        • Chronic disease and illness care
        Adding principles of family medicine to address ongoing health system redesign.
        Carmel M. Martin. Canadian Family Physician. Le Médecin de famille canadien. 53. december 2007: 2086-2091
        • Coleman K.
        • Austin B.T.
        • Brach C.
        • Wagner E.H.
        Evidence on the Chronic Care Model in the new millennium thus far, the evidence on the Chronic Care Model is encouraging, but we need better tools to help practices improve their systems.
        Health Aff. 2009; 28: 75-85
        • Byrne D.
        • Silk B.
        Acute medical units: review of evidence.
        Eur J Intern Med. 2011; 22: 344-347
        • Bell D.
        • Skene H.
        • Jones M.
        • Vaughan L.
        A guide to the acute medical unit.
        Br J Hosp Med (Lond). 2008; 69: M107-M109
        • Subbe C.P.
        • Kruger M.
        • Rutherford P.
        • Gemmel L.
        Validation of a modified early warning score in medical admissions.
        QJM. 2001; 94: 521-526
        • Silke B.
        • Kellett J.
        • Rooney T.
        • Bennett K.
        • O'Riordan D.
        An improved medical admissions risk system using multivariable fractional polynomial logistic regression modelling.
        QJM. 2010; 103: 23-32
        • Kellett J.
        • Deane B.
        What diagnoses may make patients more seriously ill than they first appear? Mortality according to the Simple Clinical Score Risk Class at the time of admission compared to the observed mortality of different ICD9 codes identified on death or discharge.
        Eur J Intern Med. 2009; 20: 89-93