Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis.

BACKGROUND: To address the challenges of caring for a growing number of older people with a mix of both health problems and functional impairment, programmes in different countries have different approaches to integrating health and social service supports. OBJECTIVE: The goal of this analysis is to identify important lessons for policy makers and service providers to enable better design, implementation and spread of successful integrated care models. METHODS: This paper provides a structured cross-case synthesis of seven integrated care programmes in Australia, Canada, the Netherlands, New Zealand, Sweden, the UK and the USA. KEY FINDINGS: All seven programmes involved bottom-up innovation driven by local needs and included: (1) a single point of entry, (2) holistic care assessments, (3) comprehensive care planning, (4) care co-ordination and (5) a well-connected provider network. The process of achieving successful integration involves collaboration and, although the specific types of collaboration varied considerably across the seven case studies, all involved a care coordinator or case manager. Most programmes were not systematically evaluated but the two with formal external evaluations showed benefit and have been expanded. CONCLUSIONS: Case managers or care coordinators who support patient-centred collaborative care are key to successful integration in all our cases as are policies that provide funds and support for local initiatives that allow for bottom-up innovation. However, more robust and systematic evaluation of these initiatives is needed to clarify the 'business case' for integrated health and social care and to ensure successful generalization of local successes.

Short-term exposure to antidepressant drugs and risk of acute angle-closure glaucoma among older adults.

Acute angle-closure glaucoma (AACG) is an ocular emergency that may be precipitated by certain types of medications. Antidepressant drugs can affect a number of neurotransmitters, which are involved in the regulation of the iris, which may precipitate AACG. We used a case-crossover study design to investigate the association between recent exposure to antidepressant drugs and AACG. We identified patients with AACG among adults aged 66 years or older between 1998 and 2010 in Ontario using linked population-based administrative databases. We identified intermittent users of antidepressant medications through prescription drug claims in the year preceding AACG. We determined antidepressant exposure in the period immediately before AACG and compared it with antidepressant exposure in 2 earlier control periods. We used conditional logistic regression to determine the odds ratio for antidepressant exposure in the hazard period compared with the control periods. A total of 6470 patients with AACG occurred during the study period. The mean age of the patients was 74.3 years, and 66% were female. Overall, 5.6% of individuals were intermittent users of antidepressant drugs in the year preceding AACG. The odds ratio for any antidepressant exposure in the period immediately preceding AACG was 1.62 (95% confidence interval, 1.16-2.26). An increased risk of AACG was also observed in several subgroups. We conclude that recent exposure to antidepressant drugs is associated with an increased risk of AACG. Clinicians should remain vigilant for the development of this uncommon but potentially serious adverse event after initiating antidepressant therapy.