Table 2.

Categories of identified patient populations with complex health and social needs.

CATEGORIES OF PATIENT POPULATIONS WITH COMPLEX NEEDS	IDENTIFIED TARGET POPULATIONS IN INCLUDED STUDIES
1. Patients with severe mental illness	Patients with moderate to severe depression [43,52]
2. Patients with common or severe mental illness + chronic condition(s)	Adults with severe and persistent mental illness who had developed type II diabetes [55] Patients with poorly controlled diabetes mellitus, coronary heart disease or both and comorbid depression [53] Patients aged 60 years and over with depression and osteoarthritis pain [58]
3. Patients with social vulnerability + chronic condition	Low-income, ethnically diverse populations at elevated risk of cardiovascular disease events, including those with existing coronary heart disease or diabetes [44] Diabetic patients at high risk for complications, in an underserved Hispanic population [45] Underserved, uninsured community with type II diabetes [70]
4. Older people with physical, cognitive, psychosocial or psychiatric vulnerabilities (+ significant healthcare use)	Community-dwelling frail people aged 60 and older [72] Community-dwelling frail older people (> 70 years) [49,51] Patients aged 70 years and over at increased risk of functional decline [71] Frail persons aged 65 years and over at increased risk of functional decline [68] Older patients with multimorbidity and functional disability and who had generated high insurance expenditures for health care [32] Community dwelling older people with disabilities and recent significant health care utilization [60] High risk patients with disability (or their caregiver) and recent significant (or expected) health care utilization [59] The most vulnerable older adults (based on patient’s categories of diagnoses and disease severity to predict medical expenditures) [56] Chronically ill community dwelling older people at high-risk for mortality, functional decline, or increased health services use [50]
5. Old age people + chronic condition(s)	Older people with chronic and complex illness who are at risk of further exacerbation and/or hospitalisation [66] 65 years of age and older with multimorbidity [33] Community-dwelling older adults with dementia symptoms and their informal caregivers [47] Patients aged 70 years and over, living at home, and diagnosed as having dementia [57] Older people with chronic conditions [48]
6. Patients living a transition to end-of life/palliative stage	Patients with varying stages of cancer progression [61,69]
7. High costs and frequent users of health care services	Frequent users of healthcare services who had chronic diseases [46]