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XXVIII Seminario dei Laghi
I SERVIZI SANITARI IN RETE
DAL TERRITORIO ALL’OSPEDALE
AL TERRITORIO
La sanità in rete: un ponte tra
medicina delle evidenze e mondo reale
Roberto Bernabei, M.D.
Centro di Medicina dell’ Invecchiamento
Università Cattolica del Sacro Cuore - Roma
Gardone Riviera – Brescia, 20 ottobre 2006
Malato Anziano Fragile
FRAGILITA’
Comorbidità
Politerapia
Stato funzionale
Con quale modello
assistenziale
Stato
cognitivo
Funzione fisica
Tono dell’Umore
Stato sociale
Incontinenza
Malnutrizione
Cadute
Osteoporosi
Con quale
metodologia
Sperimentazione modelli
innovativi in Italia (1990-2006)
Bergamo
Monza
Rovereto
Vittorio Veneto
Venezia
Jesi, Macerata, Pesaro
Regione Marche
Lecce
Regione Umbria
Chiavari
Brindisi
Arezzo
Pescara
Bari
Foggia
Roma C
Olbia
Andria
Regione
Regione
Molise
Basilicata
Avellino
Ragusa
Castrovillari
Regione Sicilia
2004;57:832-836
Età
65-74
75-84
85+
Solitudine
P. economici
Diagnosi
1-2
3-4
5+
P. ospedaliz.
1
Odds Ratio
2
OSPEDALE
Modello
Organizzativo
VMD
TERRITORIO
HEALTH SETTINGS
(GP, Hospital, NH, HC)
Organization
CGA
General
Practitioner
Home
ELDERLY PEOPLE
Community Geriatric
Evaluation Unit
(Case Manager)
Hospital
Eligible
CARE PLAN
General Practitioner +Case Manager + Community Geriatric
Evaluation Unit
Home care
Day hospital
Hospital
Nursing home
Bernabei et al, Br Med J 1998; 316:1348-51
Functional status after 1 year
of follow-up
* ADL
* IADL
* SPMSQ
* GDS
10
5
0
-5
-10
-15
Treated
Control
* p < 0.01
Bernabei et al, Br Med J 1998; 316:1348-51
Institutionalisation
(hospital + nh)
Treated
Control
Months
HEALTH SETTINGS
(GP, Hospital, NH, HC)
Organization
CGA
interRAI
Nordic Countries
Iceland, Norway, Sweden, Denmark, Finland
North America
Canada
US
Middle East
Israel
Europe
Netherlands, Germany,
Switzerland,
France, UK
Italy,
Spain,
Czech Republic
Australasia
Japan, South Korea, Taiwan, Hong Kong
Australia, New Zealand
Home Care
BERGAMO
District 1 = 95 patients
District 2 = 92 patients
Randomisation District 1 and District 2
District 1 - MDS-HC
District 2 - Geriatric Assessment with
(Barthel, MMSE,Lawton
to compare outcomes)
Barthel, MMSE, Lawton
2 patients refuse
4 patients refuse
3 patients died
88 patient completed 1 year of follow-up
2 patients died
88 patient completed 1 year of follow-up
Landi F. et al., JAGS 2001;49:1288-1293
Use of Home Care (1-year of follow-up) in the
treated and control groups
Mean (SE)
Treated
Home help
(h/year/patient)
Nursing help
(h/year/patient)
Physiotherapy
(h/year/patient)
General practioner
(h/year/patient)
Control
P
59.2  18.0
14.7  5.6
0.02
28.3  5.1
22.9  2.1
0.3
11.2  2.1
10.2  1.6
0.7
9.8  1.2
10.1  1.3
0.8
Landi F. et al., JAGS 2001;49:1288-1293
Per ricovero
ADL IADL CPS
ESPERIENZA ASL
BERGAMO
*
0
20
40
Trattati
*
60
0
Media indici funzionali (12 mesi)
*
Per persona
*
10
20
30
Media giorni di degenza in ospedale
Controlli
*
p vs. trattati < 0.001
Landi F. et al., JAGS 2001;49:1288-1293
Hospitalization during follow-up
1,0
Treated
,9
,8
,7
Control
P=0.05 (log rank test)
,6
0
100
200
300
400
Time before hospitalisation
Landi F. et al., JAGS 2001;49:1288-1293
A new model of integrated home care for the
elderly: impact on hospital use.
Landi F., Onder G., Russo A., Tabaccanti S., Rollo R., Federici S., Tua E.,
Cesari M., Bernabei R
Per persona Per ricovero
*
*
0
Trattati
10
20
Media giorni di degenza in ospedale
Controlli
30
* p vs. trattati < 0.001
Landi F. et al., J Clin Epidemiol 2001;54:968-70
Comprehensive Geriatric Assessment
Make the physical exam complete
Patient level
Better care plan
Prognostic
factors
Population level
Database
Outcome
measurements
Quality control
indicators
Comparisons
Developing an evidence-base for community care
services in Europe
The Aged Home Care project
ADHOC
Reykjavik
(IS)
G I Carpenter
E Topinkova
M Schroll
H Finne-Soverei
J-C Henrard
Canterbury
Praque
Copenhagen
Helsinki
Paris
V Garms-Homolova
P Jonsson
D Frijters
L W Sørbye
G Ljunggren
Berlin
Reykjavik
Utrecht
Oslo
Stockholm
Copenaghen
(DK)
Oslo (N)
Helsinki
(FIN)
Amsterdam
(NL)
Maidstone
Ashford
(UK)
Stockholm
(S)
Prague
(CZ)
Amiens (F)
R Bernabei Rome (Principal Investigator)
Monza (I)
Nurnberg
Bayreuth
(D)
interRAI
Reykjavik
(IS)
Copenaghen
(DK)
Oslo (N)
Helsinki
(FIN)
Amsterdam
(NL)
Maidstone
Ashford
(UK)
Stockholm
(S)
Prague
(CZ)
Amiens (F)
Monza (I)
Bielefeld (D)
Minimum Data Set for Home Care
- Cognition
- Communication/Hearing
- Vision
- Mood and Behaviour
- Social Functioning
- Informal support services
- Physical functioning
- Continence
- Disease diagnoses
- Health status
- Preventive health measures
- Nutrition/Hydration status
- Dental status
- Skin condition
- Enviromental Assessment
- Service Utilisation
Death registries
Health Services Use
- ER
- Hospital and nursing home
European Home Care Services (EUHCS)
assessment form
Setting:
- Demographic characteristics
- Hospital and nursing care beds
Service structures:
- Financial structures
- Management structures
- Range and organization of services
provided
Service delivery:
- Eligibility criteria
- Referral systems
- Provision of integrated service
- Health/social professionals and
administrative personnel per patient
- Total number of patients per year
- Mean duration of service provision per
patient
- Days per week of service provision
- Night and respite care services
- Waiting lists availability
- Use of any validated assessment
instruments
- Application of any specific guideline
Case Manager e
Istituzionalizzazione in RSA
No Case Manager
Log rank < 0.001
0
3
6
9
12
Onder G, Landi F. JAGS, in press
Case Manager
Relationship between mean MDS HC IADL index and
mean MDS ADL hierarchy score by country
Carpenter I et al, Aging Clin Exp Res 2004;16:259-269
Relationship between mean MDS Cognitive Performance
Scale and mean MDS ADL hierarchy by country
Carpenter I et al, Aging Clin Exp Res 2004;16:259-269
Proposal of a service delivery integration index of
home care for older persons: application in several
European cities
• To propose an integration index of home care delivery to older
persons, to study its validity and to apply it to home care
services of European cities;
• Data are from the “the Aged in Home care”(AdHoc) study,
which includes data on older adults in home care in: Czech
Republic, Denmark, UK, Finland, France, Germany, Iceland,
Italy, the Netherlands, Norway and Sweden.
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
Integration Index (29 items)
• Comprehensive geriatric assessment
• Multidisciplinary team approach
• Team meeting for care planning
• Case manager
• Participation of GP to team meeting
• Day and night service provision
• Weekend provision
• Single entry point
• Hospital discharge management
• Decubitus care
• Catheter management
• Intra venous medication
• Nutritional therapy
• Suctioning
• Therapies (occupational, speech, psycho-social and, physiotherapy)
• Assistance for five instrumental activities of daily living (cooking, shopping, cleaning,
laundry, meals on wheels)
• Assistance for three activities of daily living (ADL: feeding, bathing, dressing)
• Assistance for two surveillance items (supervision, tele-help)
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
Score distribution of the integration index
among participating cities
Figure 1: Total score of service delivery integration (maximum 29)
Nuremberg/Bayreuth
Oslo
Ashford/Maidstone
Cities
Stockolm
Amsterdam
Reykjavik
Total score
Amiens
Helsinki
Copenhagen
Prague
Monza
0
5
10
15
20
25
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
Factor analysis
Factor analysis shows two factors accounting for 51%
of total variance:
Factor 1. including working arrangements facilitating
integration of services provided (i.e. CGA, case
manager, team meeting, multidisciplinary approach);
Factor 2. including mostly items related to social and
health care
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
The combination of these two factors shows 3 models of care:
9
REGR factor score 2 for analysis 2
1,00000
2
UK
6
IS
1
10
NO
8
S
11
D
IT
1
FI4
3
DK
0,00000
7
NL
-1,00000
5
CZ
-2,00000
3
F
-2,00000
-1,00000
2
0,00000
1,00000
REGR factor score 1 for analysis 2
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
1. Extensive social and health care with very
little integration of services (Oslo,
Stockholm, Helsinki, Copenhagen and
Amsterdam);
2. Integration of services and few or no social
and health care delivery (Monza, Reykjavik
and Ashford/Maidstone).
3. Few social and health care delivery and few
or no integration (Amiens and Prague).
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
L’assistenza all’anziano
fragile - situazione attuale
DISTRETTO
OSPEDALE (Azienda)
UVG (UOD)
DIVISIONI PER ACUTI
RSA
AD (ADI) C.DIURNI
… in futuro
DISTRETTO
AZIENDA OSPEDALE
DIVISIONI PER ACUTI
CASE
MANAGER
+
UVG (UOD)
DIVISIONI POST ACUTI
RSA
RSA
AD (ADI) C.DIURNI