Impact on hospital admissions of an integrated primary care model for very frail elderly patients.

Very frail elderly patients living in the community, present complex needs and have a higher rate of hospital admissions with emergency department (ED) visits. Here, we evaluated the impact on hospital admissions of the COPA model (CO-ordination Personnes Agées), which provides integrated primary care with intensive case management for community-dwelling, very frail elderly patients. We used a quasi-experimental study in an urban district of Paris with four hundred twenty-eight very frail patients (105 in the intervention group and 323 in the control group) with one-year follow-up. The primary outcome measures were the presence of any unplanned hospitalization (via the ED), any planned hospitalizations (direct admission, no ED visit) and any hospitalization overall. Secondary outcome measures included health parameters assessed with the RAI-HC (Resident Assessment Instrument-Home Care). Comparing the intervention group with the control group, the risk of having at least one unplanned hospital admission decreased at one year and the planned hospital admissions rate increased, without a significant change in total hospital admissions. Among patients in the intervention group, there was less risk of depression and dyspnea. The COPA model improves the quality of care provided to very frail elderly patients by reducing unplanned hospitalizations and improving some health parameters.

Predictors of quality-of-care processes in geriatric assessment units: toward a better organizational framework.

OBJECTIVES: To identify the structural and patient characteristics associated with better care processes in older vulnerable hospitalized patients. DESIGN: Retrospective study. SETTING: Forty-four Geriatric Assessment Units (GAU). PARTICIPANTS: Patients aged 65 and older who were admitted to a GAU for a fall with trauma. MEASUREMENTS: Three care processes (comprehensiveness, informational continuity, completion of advance health care directives) assessed through chart audit; 14 patient- and 23 GAU-related characteristics obtained from hospitalization records, national databases, and GAU managers. RESULTS: A total of 877 hospitalization records were included. Final models were based on multilevel modeling using stepwise variable selection. Strongest predictors of better comprehensiveness were longer hospital length of stay (LOS), higher clinical complexity (eg, higher mortality risk), and having a geriatrician as attending physician. Comprehensiveness score increased sharply up to 3 weeks LOS and then tended to plateau. Better informational continuity was associated with more comprehensive care, higher risk of mortality, acute rather than rehabilitation care, communication with community health care professionals within 48 hours after admission, and a target LOS of 3 weeks or longer. The completion of advance directives was more likely in the presence of advanced age, higher risk of mortality, cognitive impairment, discharge to another care facility, longer LOS, university-affiliated institution, and nonurban location. CONCLUSION: In GAUs, quality-of-care processes are related to both structural and patient characteristics. Our results pointed toward an organizational framework that may help to streamline the geriatric units and better use resources, notably by narrowing the admission criteria, targeting a proper LOS, improving communication with community organizations, and making systematic completion of advance directives.

Integrated models of care delivery for the frail elderly: international perspectives / Modelos integrados de asistencia para ancianos frágiles: perspectiva internacional

Introduction: Interest is growing in integrated systems of care for the frail elderly. Few such systems have been both documented and evaluated in a rigorous manner. The present article provides an international review of such systems. Methods: The literature on integrated care covered the period from 1997 to 2010, inclusive. Some 2,496 citations were identified from Age Line, PsycINFO, CINAHAL and MedLine and were reviewed. To be included in this paper, articles had to provide a good description of the care delivery system and good quality evaluations. Only nine articles were retained. Most of the articles reviewed described some form of coordinated care without evaluation. Results: There were essentially two types of models of integrated care delivery for the frail elderly. One was a smaller, community-based model that relied on cooperation across care providers, focused on home and community care, and played an active role in health and social care coordination. The second type of model was a large-scale model that could be applied at a national/provincial/state, or large regional health authority, level, had a single administrative authority and a single budget, and included both home/community and residential services. Discussion: Integrated care delivery can be achieved in various ways. Irrespective of which model is adopted, some of the key factors to be considered are how care can be coordinated effectively across different types of services, and how all the care provider organizations can be coordinated to ensure continuity of care for frail elderly persons (AU)

Introducción: Los sistemas integrados de asistencia para los ancianos frágiles suscitan cada vez más interés. Hay pocos sistemas de este tipo que hayan sido documentados y evaluados de forma rigurosa. Este trabajo presenta un estudio internacional de estos sistemas. Métodos: Correspondientes al periodo de 1997 a 2010, se identificaron y revisaron 2496 referencias bibliográficas de Age Line, PsycINFO, CINAHL y MedLine. Para ser incluidos en el estudio, los artículos debían ofrecer una buena descripción del sistema de asistencia sanitaria y unas buenas evaluaciones de calidad. Sólo se seleccionaron nueve artículos; la mayoría de ellos describían algún tipo de asistencia coordinada sin evaluación. Resultados: Principalmente se han encontrado dos tipos de modelos de atención sanitaria integrada destinada a los ancianos frágiles. Uno era un modelo comunitario pequeño basado en la cooperación entre profesionales sanitarios, se centraba en la asistencia domiciliaria y comunitaria, y tenía un papel activo en la coordinación de la asistencia sanitaria y social. El segundo era un modelo a gran escala que podía ser aplicado por autoridades sanitarias nacionales/provinciales/estatales/regionales, que tenía una autoridad administrativa única, un solo presupuesto e incluía tanto servicios domiciliarios/comunitarios como residenciales. Discusión: Hay varios modos de lograr una asistencia sanitaria integrada. Algunos de los factores clave a tener en cuenta, independientemente de cuál sea el modelo que se adopte, son cómo coordinar la asistencia entre los diferentes tipos de servicios de forma eficaz y cómo asegurarse de que todas las organizaciones asistenciales trabajan juntas para garantizar la continuidad de la asistencia para las personas mayores frágiles (AU)

Integrated models of care delivery for the frail elderly: international perspectives.

INTRODUCTION: Interest is growing in integrated systems of care for the frail elderly. Few such systems have been both documented and evaluated in a rigorous manner. The present article provides an international review of such systems. METHODS: The literature on integrated care covered the period from 1997 to 2010, inclusive. Some 2,496 citations were identified from Age Line, PsycINFO, CINAHAL and MedLine and were reviewed. To be included in this paper, articles had to provide a good description of the care delivery system and good quality evaluations. Only nine articles were retained. Most of the articles reviewed described some form of coordinated care without evaluation. RESULTS: There were essentially two types of models of integrated care delivery for the frail elderly. One was a smaller, community-based model that relied on cooperation across care providers, focused on home and community care, and played an active role in health and social care coordination. The second type of model was a large-scale model that could be applied at a national/provincial/state, or large regional health authority, level, had a single administrative authority and a single budget, and included both home/community and residential services. DISCUSSION: Integrated care delivery can be achieved in various ways. Irrespective of which model is adopted, some of the key factors to be considered are how care can be coordinated effectively across different types of services, and how all the care provider organizations can be coordinated to ensure continuity of care for frail elderly persons.

Health state profiles and service utilization in community-living elderly.

BACKGROUND: We know that health status in older people is heterogeneous and that many need complex care. What is now required is a comprehensive description of this heterogeneity and the estimation of its effects on patterns of service utilization. OBJECTIVE: This study examines the possibility of classifying older people according to their complex health conditions and whether the way in which they consume services differs based on these classes. METHODS: We used latent class analysis to model heterogeneity and classify community living elderly into homogenous health state categories (ie, health profiles). The number of health profiles present in the sample was revealed using 17 health indicators collected at baseline in the demonstration project of SIPA (French acronym for System of Integrated Care for the frail elderly), a system of integrated care for frail older people (n = 1164). These profiles were then used in 2-part econometric models to study access and costs of several measures of services using data collected prospectively over the 22-months of the SIPA trial. RESULTS: We identified 4 substantially meaningful health profiles (prevalence: 23%, 11%, 36%, 30%) characterized by differences along the physical, cognitive, and disability dimensions of health. Subsequent econometric modeling showed a differential effect of health profiles on use and costs along the continuum of health and social services. CONCLUSIONS: For older people with complex care needs, classification into homogeneous health subgroups unmasks differences in utilization patterns that can be used by decision makers in their attempt to improve the trajectory of care and adjust the distribution of resources to the needs of older people.

Integrated services for frail elders (SIPA): a trial of a model for Canada.

The complex formed by chronic illness, episodes of acute illness, physiological disabilities, functional limitations, and cognitive problems is prevalent among frail elderly persons. These individuals rely on assistance from social and health care programs, which in Canada are still fragmented. SIPA (Services intégrés pour les personnes âgées fragiles) is an integrated service model based on community services, a multidisciplinary team, case management that retains clinical responsibility for all the health and social services required, and the capacity to mobilize resources as required and according to the care protocol. The SIPA demonstration project used an experimental design, with random allocation of the 1,230 participants from two areas of Montreal to an experimental and a control group. The costs of institutional services were $4,270 less for those in the SIPA group compared to the control group; the costs of community care were $3,394 more. The proportion of persons waiting in acute care hospitals for nursing home placement was twice as high in the control group as in the SIPA group. The costs of acute hospitalizations for persons in the SIPA group with ADL disabilities were at least $4,000 lower than those for persons in the control group. In conclusion, the SIPA trial showed that it is possible to undertake ambitious and rigorous demonstration projects in Canada. These results were obtained without an increase in the overall costs of health and social services, without reducing the quality of care, and without increasing the burden on elderly persons and their relatives.

A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial.

BACKGROUND: Care for elderly persons with disabilities is usually characterized by fragmentation, often leading to more intrusive and expensive forms of care such as hospitalization and institutionalization. There has been increasing interest in the ability of integrated models to improve health, satisfaction, and service utilization outcomes. METHODS: A program of integrated care for vulnerable community-dwelling elderly persons (SIPA [French acronym for System of Integrated Care for Older Persons]) was compared to usual care with a randomized control trial. SIPA offered community-based care with local agencies responsible for the full range and coordination of community and institutional (acute and long-term) health and social services. Primary outcomes were utilization and public costs of institutional and community care. Secondary outcomes included health status, satisfaction with care, caregiver burden, and out-of-pocket expenses. RESULTS: Accessibility was increased for health and social home care with increased intensification of home health care. There was a 50% reduction in hospital alternate level inpatient stays ("bed blockers") but no significant differences in utilization and costs of emergency department, hospital acute inpatient, and nursing home stays. For all study participants, average community costs per person were C dollar 3390 higher in the SIPA group but institutional costs were C dollar 3770 lower with, as hypothesized, no difference in total overall costs per person in the two groups. Satisfaction was increased for SIPA caregivers with no increase in caregiver burden or out-of-pocket costs. As expected, there was no difference in health outcomes. CONCLUSIONS: Integrated systems appear to be feasible and have the potential to reduce hospital and nursing home utilization without increasing costs.

Caregiver satisfaction with support services: influence of different types of services.

OBJECTIVES: This article examines factors influencing satisfaction with support services of caregivers of frail older adults and determines what types of support services are associated with greater satisfaction, controlling for frail individual and caregiver characteristics. METHODS: The study includes 291 frail older adults-caregiver dyads from Montreal in which caregivers receive support services. The Client Satisfaction Questionnaire-8 is used to measure caregiver satisfaction with these services. RESULTS: Caregivers receiving information, advice, or emotional support, and those caring for seniors receiving integrated care are more likely to be highly satisfied. Other factors increasing satisfaction are fewer number of health problems of frail individuals, caregiver being the spouse of the frail person, as well as greater caregiver perceived health, autonomy in instrumental activities of daily living, and available social support. DISCUSSION: The results support the importance of integrated care for frail seniors and informational services for their caregivers.

International experiments in integrated care for the elderly: a synthesis of the evidence.

BACKGROUND: The OECD countries have recently promoted policies of deinstitutionalisation and community-based care for the elderly. These policies respond to common cost pressures associated with population aging, and the challenge of providing improved care for the elderly. They aim to substitute less costly services for institutional ones, to improve patient satisfaction and decrease expenses. However, views concerning their success are mixed. We took a comparative cross-national approach to examine the evidence, to identify common features of an effective system of integrated care, and to examine the potential of such models to positively affect care of the elderly, and public finances. METHODS: We conducted a systematic review of recent demonstration projects testing innovative models of care for the elderly in OECD countries. Projects included aimed to create comprehensive integration of acute and long-term care services, and were evaluated using a comparison group. RESULTS: For each project, we report available results on rates of hospitalisation, long term care institutionalisation, utilisation and costs, impact on process of care, and health outcomes. In addition, the following common features of an effective integrated system of care were identified: a single entry point system; case management, geriatric assessment and a multidisciplinary team; and use of financial incentives to promote downward substitution. CONCLUSIONS: Community-based care can impact favourably on rates of institutionalisation and costs. Comprehensive approaches to program restructuring are necessary, as cost-effectiveness depends on characteristics of the system of care. Expansion of successful programmes to achieve widespread use remains a critical challenge.