Current care practices for adolescents with persistent patterns of frequent attendance to emergency departments (ED) focus on acute crisis and behaviour management. These adolescents are more likely to have certain sociodemographic and health characteristics including older age, child protection involvement, chronic mental health concerns, medical co-morbidities, and lack of General Practitioner (GP) continuity of care[1]. Exploration of the underlying reasons for long term use of emergency services by adolescents is needed. [1] Parry H, Roxburgh E, Maier L, Louise J, Hill M, Berry C. Frequent attendance to paediatric emergency departments: Steps towards prevention. Emergency Medicine Australasia (2025) 37, e70037This GP-led research seeks to: 1. Increase understanding of underlying reasons for adolescents persistent frequent ED attendance 2. Explore perceptions from GPs, emergency clinicians, and parents/ guardians 3. Explore perceptions of the role health services including longitudinal GP careIn a prospective qualitative study, inductive content analysis was used to identify themes from interviews conducted on 12 GPs, 12 paediatric emergency clinicians, and 15 parents/ guardians of 8 adolescents aged 12-15 years who had attended a tertiary paediatric emergency department > 5 times per year in 2 consecutive years.There were common themes across all 3 interview groups. Primary and tertiary health services are siloed with poor communication and collaboration. Adolescents with complex needs require time to build trusted therapeutic relationships. Current models of care prioritise compliance and risk mitigation over the needs of adolescents.These findings support a broadening of the focus of health care for adolescents with persistent emergency service attendance. These include review of policies to reflect the needs of adolescents, communication systems, proactively connecting high risk children and adolescents with a GP they trust for relationship-based regular, planned care.A targeted early intervention and prevention approach including connecting high risk children risk with relationship-based GP care is recommended. Improved communication, collaboration and policy development prioritising the needs of children and young people requires further exploration.

The increasing use of Emergency Services (ES) in XXX represents a challenge, as many cases could be managed in primary health care (PHC). ES overuse is concentrated among a minority of patients with higher clinical complexity, making it essential to understand their profile to guide effective interventions.To characterize adult ES hyperusers (≥5 visits) from XXX Hospital, enrolled in Family Health Units in the XXX region, and to analyze their PHC utilization.Observational, cross-sectional, analytical study conducted in 2023, including 319 patients aged ≥18 years. Data were collected from XXX® and XXX® platforms, including sociodemographic, clinical, behavioral variables, and PHC utilization. Statistical analysis included descriptive statistics, non-parametric tests, Spearman correlations, and Poisson regression.Median ES visits per patient was 6; 70.2% were female, median age 55 years. Multimorbidity was highly prevalent (85.9%) - particularly cardiovascular, musculoskeletal and respiratory conditions. Polypharmacy affected 46.7%. In PHC, the median number of consultations was 5, indicating that many hyperusers also actively use primary care. Physical activity was associated with fewer urgent visits. Patients with neurological conditions had more health care contacts in both ES and PHC. Employed patients used the ES less and distance to ES/PHC did not influence visit frequency.Our results suggest that multimorbidity, particularly neurological disorders, may play a significant role in hyperuse, consistent with recent literature. Physical activity demonstrated a protective effect, highlighting the role of health behaviors in ES use. High PHC utilization indicates that these patients are not disconnected from the system but represent a group with high clinical complexity. The lower use of ES by employed patients suggests a “healthy worker effect”. Interestingly, distance to ES or PHC did not influence visit frequency, suggesting that in a context of well-distributed primary and emergency care services, geographic proximity is less relevant than clinical and behavioral factors.Early identification of ED hyperusers, structured management of multimorbidity, and promotion of healthy lifestyles in PHC may reduce avoidable acute episodes and improve overall health care efficiency. Developing health policies that ensure appropriate follow-up of these patients in PHC is therefore essential.

Primary Care Services (PCS) are challenged by a small group of High Users (HU) who account for a disproportionate number of visits over multiple years. These patients often present with multimorbidity, socioeconomic vulnerability, and fragmented care, leading to poorer outcomes and increased system strain. Despite their importance, HU trajectories remain insufficiently understood, and available tools do not adequately support early identification or coordinated management. Digital Twin (DT) technology, defined as dynamic, AI-driven digital replicas of patients, offers an opportunity to address this gap in PCS.This work aims to conceptualize a DT solution to support HU management in PCS and to define a structured use case grounded in real-world needs. Specifically, we seek to (i) characterize HU challenges and trajectories, (ii) integrate stakeholder perspectives into DT design, and (iii) identify functionalities enabling clinical, organizational, and patient-level decision-making.A Participatory Action Research (PAR) methodology was used, progressing through iterative cycles of planning, action/observation, and reflection. Data collection included semi-structured interviews, journey-mapping sessions, focus groups, impact-mapping exercises, and workshops. Participants included clinicians, patients, administrators, researchers, policymakers, and developers. Insights were prioritized using MoSCoW ranking and a Real-Time Delphi process to reach consensus on key DT features.Stakeholders identified recurrent HU patterns, including multimorbidity, unresolved care episodes, and organizational inefficiencies,  along with gaps in coordination, risk prediction, and patient literacy support. Consensus emerged that a DT should integrate multimodal data, model HU risk trajectories, generate early warnings signals, support personalized care plans, and assist administrators in resource planning. The final use case specifies the primary actor (clinicians), the goal (early identification and proactive HU management), and a DT architecture composed of data-integration pipelines, predictive-modelling components, interface-design requirements, and continuous synchronization mechanisms.The PAR approach captured the multidimensional nature of HU and ensured that the DT concept addressed clinical, managerial, and patient priorities. Although implementation was beyond this phase, the co-designed use case is considered feasible for PCS.A participatory DT design process can strengthen HU management by improving risk stratification, care coordination, and system efficiency. This framework can guide future development, testing, and policy integration in PCS.

The phenomenon of High-Need/High-Cost (HNHC) patients—individuals with frequent, often avoidable hospital and emergency department use—has emerged globally as a critical policy concern. Despite two decades of interventions, these patients are still framed as undermining health system efficiency. This narrative review critically explores how HNHC has been constructed and operationalized in policy, research, and care delivery.This narrative review critically explores how HNHC has been constructed and operationalized in policy, research, and care delivery.Using a multi-phase, constructivist methodology grounded in Critical Systems Heuristics (CSH), the study began with an inductive scan of key literature and international feedback from primary care researchers. Thematic analysis was built through iterative keyword refinement, snowball sampling, and conceptual coding. Only after coding saturation was achieved was the CSH lens applied to assess the assumptions, stakeholder perspectives, and systemic framings shaping the HNHC discourse.The results show that the rise of the Triple Aim paradigm—focusing on care quality, population health, and cost—has driven global interest in super-utilization. Labels such as “frequent flyer” or “high-utilizer” reduce complexity to econometric metrics, often ignoring the lived experience, structural inequities, and expected distribution patterns (e.g., 80:20 Pareto principle). Intervention studies—mostly care coordination or case management—were narrowly evaluated using utilization or cost outcomes. Equity, relational continuity, and social determinants of health were acknowledged but rarely integrated into program design or evaluation. More recent concepts like the Quintuple Aim include equity and workforce well-being, yet practical uptake remains limited.The research literature and evaluation tools heavily reflect systemic priorities rooted in cost containment. As a result, patient-centered and complexity-informed approaches remain peripheral. A shift is needed—from reactive, transactional care to proactive, anticipatory strategies that strengthen community resilience and empower high-need populations.High-need patients should not be seen as system failures, but as individuals whose journeys can guide better care design. A complexity-informed, equity-oriented framework—grounded in the lived realities of patients, caregivers, and frontline providers—can support more responsive, sustainable, and just care models.

Originally developed in military settings to prioritise wounded individuals, triage has been adapted to primary care (e.g., the French Service d’Accès aux Soins and the UK “Total Triage” model) to optimise the management of requests before consultation. Although rarely implemented in French primary-care group practices, triage could improve patient flow in the context of high demand and workforce constraints.To assess satisfaction and utilisation patterns associated with a questionnaire-based triage tool used for online urgent consultation requests in general practice.We conducted a prospective, quantitative, observational study among patients and general practitioners participating in a capitation-based payment programme. When booking an online appointment for an “urgent” reason, patients could complete a triage questionnaire. The tool generated orientation recommendations: national health information sheets (Ameli), telephone advice within 48 hours from the patient’s general practitioner, in-person or remote consultation, or urgent call to the national emergency number (15). Patient and clinician satisfaction was collected through structured questionnaires, and triage orientation data were extracted from the electronic medical record.Over 12 months, 898 orientations were generated: • 32 (4%) to information sheets • 597 (66%) to telephone advice • 252 (28%) to a consultation • 7 (1%) to the emergency number (15) Among those oriented to telephone advice: • 35% booked a consultation directly • 45% consulted within 48 hours and 8% within 7 days • 12% did not consult within 7 days Overall, 93% (57) of triage users rated the tool as highly satisfactory, and 67% (232) of general practitioners judged the orientations to be highly appropriate.The tool was well accepted by patients but generated more mixed perceptions among clinicians, largely due to the limited use of information sheets and the modest reduction in consultations. Although based on real-world data from an urban multicentre setting, generalisability remains limited. Extending triage to non-urgent requests and diversifying care pathways could enhance its operational value.Questionnaire-based triage is feasible and well received by patients but offers limited impact on reducing consultations. Broader implementation strategies may be required to optimise demand management in general practice.

Singapore’s NHG Health covers 1.5 million residents and ~600 GP clinics in the Central-North region. To reduce unnecessary referrals and enable patients to receive specialist-guided care faster, NHG Health implemented a two-tier VPC model across its three acute hospitals.Tier 1 = general clinical queries without patient identifiers via instant messaging; Tier 2 = patient-identified e-consults with secure document exchange. The NHG Health VPC model aligns each hospital with its geographical catchment while allowing GPs to join any VPC group for convenience. Specialists in selected disciplines for GPs and polyclinics are reachable through WhatsApp Communities (GPs) or Microsoft Teams (polyclinics), chosen for existing workflow compatibility. Condition-specific pathways (Tele-ECG, Tele-AF, Tele-Ortho with upfront MRI, Mental Health VPC) are embedded. Onboarding, etiquette guides and dedicated relationship managers maintain engagement; clinical governance is preserved through audit logs and response-time targets.Implementation revealed that managing multiple communication platforms creates significant administrative burden, prompting plans for a unified interface. Technical challenges around secure image sharing for dermatology consultations and cross-provider MRI transmission required development of customised consent and encryption solutions. Sustaining specialist engagement necessitates protected time allocation and formal recognition within performance appraisals. Early outcomes from July-September 2025 demonstrated promising results, with 59% of Tele-ECG cases and 63% of orthopaedic consultations avoiding tertiary care referrals, indicating both clinical safety and healthcare capacity benefits. Continuous feedback mechanisms and systematic outcome tracking will inform the planned expansion to 22 specialties across NHG Health's three hospitals by June 2026.A flexible, regionally-adapted VPC model can strengthen primary-specialist integration without major capital investment. Success depends on aligning communication tools with existing clinician behaviour, ensuring governance, and embedding pathways for high-volume conditions.NHG Health’s VPC demonstrates rapid, scalable primary-specialist collaboration, offering a replicable template for healthcare systems seeking timely, cost-effective integration.