Health problems of the elderly : Do we need more integration ?

EFPC Conference, İstanbul, 2013

Health problems of the elderly: Do we need more integration?Prof. Güzel Dişçigil, Adnan Menderes

Univ, Medical School, Family Medicine Department

Asistant Prof. Serap Çifçili, Marmara Univ, Medical School, Family Medicine Department


Program15:00-15:20 Wellcome and introduction15:20-15:40 Presentation: Current health services and status of the elderly in Turkey. (Güzel Dişçigil)15:40-15:50 Brain storming: Challenges of primary care in terms of care for the elderly focusing on integration and co-ordination of care.15:50-16:20 Coffee Break and formation of the groups16:20-16:40 Presentation: Care for the elderly: Integration of care across Europe(Serap Çifçili)16:40-17:00 Group discussions about solutions to our problems17:00-17:15 Sharing ideas that came up in the groups.

WELLCOME


Serap ÇifçiliMarmara University Medical School

Care for the elderly: Integration of care across Europe


What is integration of care1?“the purposeful working together of independent elements in the belief that the resulting whole is greater than the sum of the individual parts” (Woods, 2001).

1. MacAdam M. Frameworks of Integrated care for the Elderly: A Systematic Review. CPRN Research Report, April 2008 (http://www.insp.mx/geriatria/acervo/pdf/60%2049813_EN.pdf)


What is integration of care1?“a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion”. (WHO European Office for Integrated Health Care Services).

“a means to improve the services in relation to access, quality, user satisfaction and efficiency” (Grone and Garcia- Barbero, 2001).


Why is it needed1?Poor quality of care being delivered to those with chronic conditions.

Episodic, short-term intervention to long-term, comprehensive care

Acute care needs Fragmentation of care


Why is it needed1?

To improve integration of continuing care services.

Care of the elderly has been a particular focus with one or more chronic conditions, their high use of health care services


The Goal:

To improve accessibility, quality of care and financial sustainability


Terminology1 (Leutz 1999)Linkage; allows individuals with mild to moderate health care needs to be cared for in systems that serve the whole population without requiring any special arrangements.Coordination; requires that explicit structures be put in place to coordinate care across acute and other health care sectors. While coordination is a more structured form of integration than linkage, it still operates through separate structures of current systems.


Terminology1 (Leutz 1999)

Full integration creates new programs or entities where resources from multiple systems are pooled.


Does it work and what kind?

Bird et. al. (2007) Integrated Care Facilitation for Older Patients with Complex Needs Reduces Hospital Demand, Australia

Intervention: Case management, facilitated access to health and socail services, self-management educationOutcome: %21 reduction in ER visits%28 reduction in admissionsCost-effective over the existing system (1M$)


Does it work and what kind?

Beland et. al. (System Integrated Care for Older Persons, Canada) SIPAIntervention: Case management, multidisciplinary teams, home support services, clinical protocols, intensive home care, 24 hour on-callOutcome: No additional cost, increased client satisfaction, no cost savings.


Does it work and what kind?US department of Health and Human Services. Program for All-Inclusive Care of the Elderley (PACE). Intervention: Case management, interdisciplinary team, adult day care, access to supportive health and social services, capitation paymentOutcome: Lower rates of hospital use, NH and ER visits, lower mortality, better health stastus and quality of life. No cost savings.


Does it work and what kind?Barnabel et.al. (1998, Italy). Integrated care.

Intervention: case managemnt, geriatric evaluation, involvement of GPs, coordianed health and social service delivery.

Outcome: Reduced use of hospial and nursing home, improved physical and cognitive function. Cost-effective.


Does it work and what kind?Department of Health and Ageing. Coordinated health Trials (Australia 2001, 2007).Intervention: Assessment and care planning, Enhancement of GP roles in some locations. Outcome: • Round-1; No impact on health and well-being, increased

use of community services, expenditures were greater.• Round-2; Improved health and well-being and access to

health services, indications of cost-effectiveness.


Does it work and what kind2?Darlington (UK) Challis D, Hughes J. Intervention: Case finding and screening, Assessment, Care planning, Monitoring and review, Case closure Outcome: Reduced the rates of institutionalization (50% at home after 12 months), increased the number of days at home (137 days versus 12 days), Increased the use and appropriateness of community services, increased morale, patient satisfaction and depression; limited generalizability due to the requirement for extensive social support or only moderate dependency


Primary care for older persons in Europe 3

Quality of care for older persons (professionals’ opinion, France)1- Inadequate needs assessment process within primary care2- Inadequate coordination of primary care services3- Inadequate coordination of primary and secondary care4- Perceived consequences for patients and families


Primary care for older persons in Europe 2

Stronger PC systemGeneralist approach, first point contact of care, oriented to the context and community, provides continuity and comprehensiveness

Weaker PC system

UK PortugalNordic countries (Denmark, Finland, Iceland, Norway, Sweden)

France

Spain BelgiumNetherlands SwitzerlandItaly Greece

AustriaGermany


Unmet needs3 • Health needs, mobility needs, personal needs, housework needs• 6 countries; Greece, Italy, Poland, UK, Germany, Sweden.

Higher use of social care and integrated services

3. Bien B, McKee KJ, Dohner H, Triantafillou J, Lamura G, Doroszkiewicz H, Krevers B, Kofahl C. Disabled people’s use of health and social services and their unmet care needs in six European countries. The European Journal of public Health 2013;1-7.

% of care receivers with unmet needs

Greece

Italy Poland

UK Germany

Sweden

Health needs 61,5 50,4 39,9 25.5 27.9 14.9Mobility needs 61.1 49.8 38.1 33.0 37.5 20.7Personal needs 58.9 48.8 32.2 33.6 32.8 17.9Housework needs 58.5 45.5 38.1 29.8 32.1 15.3


Patent’s perspective2

• Patient centered and individualised• Easy accsess to providers (telephone, internet, in person)• Clear communication of individualised care plans• Support from a single coordinator• Continuity of relationships


Comprehensive Care

•Practice guidelines, Disease Oriented programs•Different guidelines, multiple providers

Multi-dimensional geriatric assessmentsSTEP, EASY-care; outcome?


Comprehensive Care

• Integrating Services•Multidisciplinary team-work; community nurses, pharmacists, social workers

Single coordination of care (generally GP)GPs are not well positioned to do the full clinical coordination


Integrating services• Single entry point in Italy (SEPs), GP is a proactive actor • Case management by community matrons, UK• Coordination of Professional Care for the elderly (COPA), GP and manager work together, targets old persons living alone.• a single entry point; reinforced the role played by the GP, • integrated health professionals into a multidisciplinary primary care team that includes case managers, • introducing geriatricians into the community who intervene upon a GP request.


References1. MacAdam M. Frameworks of Integrated care for the Elderly: A

Systematic Review. CPRN Research Report, April 2008. 2. Johri M, Beland F, Bergman H . International experiments in

integrated care for the elderly: a synthesis of the evidence . Int J Geriatr Psychiatry. 2003 Mar;18(3):222-3.

3. Boeckzstaens P, De Graaf P. Primary care and care for older persons: Position Paper of the European Forum for Primary Car. Quality in Primary Care 2011;19: 369-89. European Forum for Primary Care, Almere, The Netherlands. On behalf of the Position Paper Working Group: Aggie Paulus, Arno Van Raak, Peter Groenewegen (The Netherlands), Carmen de la Cuesta (Spain), Danica Rotar (Slovenia), Hanna Kaduskiewicz, Martina Hasseler, Ulrike Junius Walker (Germany), Isabelle Vedel (Canada), Jan De Lepeleire, Janneke Ronse, Jean- Pierre Baeyens (Belgium), Modesta Visca (Italy), Steve Illife (UK)

4. Bien B, McKee KJ, Dohner H, Triantafillou J, Lamura G, Doroszkiewicz H, Krevers B, Kofahl C. Disabled people’s use of health and social services and their unmet care needs in six European countries. The European Journal of public Health 2013;1-7.

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Health problems of the elderly : Do we need more integration ?