INCAP

INCAP - Integrated Multiprofessional Primary Care Model for Patients with Moderate to Severe Post-Acute Infection Syndrome (PAIS) / Integrated Multiprofessional Primary Care Model for Severely Affected Patients with Post-Infection Syndrome

Background:
Post-acute infection syndromes (PAIS), particularly post-COVID syndrome (PCS) and post-infectious myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), pose a growing challenge to the healthcare system due to their often long-lasting and complex symptoms. While many affected individuals have a favorable course, some patients suffer from severe and persistent symptoms that significantly impair their quality of life and ability to participate in daily activities. To date, care for these individuals has been characterized by unclear responsibilities and difficult access to specialized services.

The guideline published by the Joint Federal Committee (G-BA) on interdisciplinary, coordinated, and structured care for people with post-COVID syndrome and similar symptoms forms the basis for new care approaches. However, implementing these requirements poses a challenge, as existing care structures have so far been only partially tailored to the specific needs of people with PAIS.

Methodology
The INCAP project is investigating the implementation of an integrated care model for patients with moderate to severe PAIS in Baden-Württemberg. Following a structured assessment of symptoms and eligibility for the study, enrolled participants receive support through a regional care and case management system. This system assists patients in prioritizing their symptoms, coordinates subsequent care steps, and refers them to specialized primary care practices (SPVP).

At the SPVP, a comprehensive primary care assessment is conducted, and an individualized care recommendation is developed, taking existing outpatient structures into account. In complex cases, digital, interdisciplinary case conferences involving experts from the participating university hospitals facilitate joint coordination of diagnostic and treatment options. The goal is to return patients to standard care after specialized treatment with a coordinated recommendation and to enable needs-based follow-up care there.

The multicenter care study evaluates the feasibility, acceptance, and effectiveness of the care model. To this end, patient-centered outcomes, changes in the perceived quality of care, and structural aspects of implementation are examined. In addition, care data will be analyzed to assess the impact on utilization and care pathways.

Objective

The objective of the project is to establish and scientifically evaluate a coordinated, multiprofessional, and sustainable care structure for people with moderate to severe PAIS. INCAP aims to help close gaps in care, better coordinate complex treatment pathways, and develop a transferable model for the future care of patients with PAIS. In the long term, the findings are intended to lay the groundwork for integrating the care model into standard care.