Evidence-based public h e a l t h 0 Harc'o~rt Brace and Company Ltd 1998

h tegrating social and medical services for frail elderly living in the community improves outcomes and decreases overall costs of care

~OMMENTAR3

Bernabei R, Landi F, Gambassi Get al. Randomised trial of impact of model of integrated care arid case management for older people living in the community. BMJ 1998; 316:1348-1351

Objective

To determine the effect of an integrated social and medical care system for frail elderly living in the community.

Setting

Town in northern Italy.

Method

Randomized study with 1-year follow-up.

Literature search strategy

None listed; 18 references.

Subjects

200 elderly residents receiving conventional community care services.

Main interventions

I00 elderly were randomized to the treatment group to receive integrated social and medical care services with cage management. Case managers were intensively trained in geriatric assessment technology and case management skills in

order to design care plans and coordinate agencies (i.e. community geriatric evaluation units and general practitioners (GPs)).

Outcome measures

Hospital and nursing home admissions, use and cost of health services and changes in functional status.

Results

The cumulative number of days spent in nursing home or acute hospital was reduced by almost half in the treatment group. The integration of services also resulted in better outcomes for medications, GP home visits (fewer needed in both cases, relative to controls) and functional status (with greater deterioration in functional status for the control group). The treatment was estimated to save £1125 ($1800) per person per year, mostly from lower nursing home and hospital expenses.

Conclusions

Integrated social and medical services with case management may be a cost effective approach to caring for the frail elderly residing in the community.

Community care for older people does not attract the same degree of public and media interest as community care for psychiatric illnesses, but not surprisingly has a higher cost, predicted to rise dramatically as the populat ion ages.

This high-qual i ty study from Italy brings scientific discipline to the evaluation of community care, an area where there have been few randomized trials. The careful use of observers unaware of the care patients received removes a common bias that exists in many studies in this area, and improves confidence in the results.

This was a frail populat ion, wi th an average age of 81. From the control group who received normal care, 17% attended A&E departments, and 51% attended hospital for care during the year. This fell to 6% and 38% respectively in the intervention group.

The main difference that this intervention group received was the ' formal agreement between multidisciplinary groups and local health agencies' and the provision of two case mangers to look after 100 patients. This degree of management and cooperation is impressive and should be a model for care elsewhere. Overcoming resistance between agencies and departments, all trying to protect their budgets, is one of the principles that underpins the formation of Health Action Zones in the UK. These are currently being evaluated as possible ways of improving cooperation between care agencies. 1

This study should encourage everyone involved in improving care in the community. Improving multidiscipllnary team work ing and actively managing care seem to be effective, and policy makers should support work and further evaluative studies in this area.

lan Reeves Specialbt Registrar in Geriatric Medicine

Stobhill Hospital Glasgow, UK

Reference

1. United Kingdom Department of Health Press Release. htt p'J/www.coi.g ov.u k/coi/d e pLVG D H/ coi9818d.ok

90 EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT DECEMBER 1998