Transcript The Complexity of Care for Older Persons

The Complexity of Care for
Older Persons
Howard Bergman MD, FCFP, FRCPC
Chair, Department of Family Medicine
Professor of Family Medicine, Medicine and Oncology
The Dr. Joseph Kaufmann Professor of Geriatric Medicine
McGill University
The Complexity of Care for Older Persons
Howard Bergman, MD, FCFP, FRCPC
Chair, Department of Family Medicine
Professor of Family Medicine, Medicine and Oncology
The Dr. Joseph Kaufmann Chair of Geriatric Medicine
McGill University
17.3.12
Family Medicine
Médecine de famille
The Shifting Face of Health Care
 From acute to chronic disease
 From institutions to networks of care; from a single site (hospital,
nursing home) to many sites: home, assisted living, supportive
housing, physician’s office, community clinics, ambulatory care
centers, community hospitals, academic health centers,
rehabilitation facilities, nursing homes, palliative care centers
 From a single professional, generally a physician to many health
care professionals: family doctors, specialists, nurses, physical
therapists, nutritionists, social workers, psychologists, etc.
 Expectations/knowledge/Involvement of patients and family
The Shifting Face of Health Care
↑ Complexity
↑ Interdependency
↑ Uncertainty
 Increasing preoccupation with costs and
performance leading to increased government
intervention/control/reform
 Continuous Change
Health care systems and the challenge of
aging
↑ old, old-old
↑ life expectancy
– In developing countries as well: sanitation, nutrition, living
conditions, education, infectious disease control, med care
↑ chronic diseases
– In developing countries as well: ↑ life expectancy, changes in
nutrition, physical activity, ↑ tobacco, med care
↑ chronic diseases +↑ life expectancy
=
Aging with ↑ disability
Bovet P. Tropical Medicine and International Health 2001
Heath care systems and the challenge
of aging
Potential for promotion/prevention promoting healthy
aging and in at least delaying onset of frailty and
disability
– Interaction: health/functional status/social status and support
– Importance of chronic disease and impact on quality of life and
progression to disability
↑ complex interventions (technology/medication) in
increasingly older persons
Health care systems poorly adapted to the management of
chronic disease, frailty and dependency; complexity of
treating chronic diseases and frail older persons
Health and functional status of cancer patients, aged 70 years and older
referred for chemotherapy- preliminary findings
100
80
%
42%
(n=21)
60
40
20
12%
(n=6)
30%
(n=15)
16%
(n=8)
0
Without frailty
With frailty
markers or IADL /
markers but
ADL disability without IADL /
ADL disability
IADL disabled
without ADL
disability
ADL disabled
Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H.
Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for
chemotherapy Journal of Gerontology; Medical Sciences (In Press)
Comorbidities
ADL dependency
Monitoring
Intervention
médicale
Complex care
Monitoring
Multidisciplinary
care
Frailty
Monitoring
Prevention
Health
promotion/prevention
Screening
Acute care
Focus on very frail older persons with
disabilities
Generally over 75
Disabilities in ADL/IADL
Acute and chronic medical problems
Importance of social network
Frequent transitions, high utilisation and costs:
community, hospital, rehab, NH
– 20% of older persons=3% population=30% costs
Need for a complex combination of medical
and social services-acute and continuing care
Focus on integration of care for very frail
older persons with disabilities
Increase in number of older persons and costs of care
Present difficulty in management
– Fragmentation; unmet needs; underutilization of effective
geriatric and care management interventions; parallel playmedical, community services; problem in quality of care;
negative incentives; inappropriate use of resources ; absence of
“comprehensive” responsibility and accountability
Increasing evidence of the effectiveness of treatment and
care management in frail older persons
Integration/Coordination
Projects
International
 Pace/On Lok (USA)
 S/HMO (USA)
 Bernabei (Italy)
 British experience-Matrons
 COPA-Paris
Canada
 CHOICE
 RISC
 Bois-Francs/PRISMA
 SIPA
SIPA characteristics
 Objective: improve health and functional status, quality,
satisfaction; decrease inappropriate hospital and nursing home
care; control costs
 Primary care responsible/accountable for a defined population
 Integrate/coordinate health, social and supportive care
 Utilisation of protocols
 Case management with more responsive care
 Align governance and financial incentives with clinical goals
Bergman, Béland, Lebel et al CMAJ. 1997; 157:1116-1121
Béland, Bergman, Lebel et al J of Gerontol, Med Sci. 2006,vol 61A, No. 4, 367–373
Clinical approach
A person centred approach based on
health/functional status for older persons with
multiple chronic diseases/disabilities/difficult social
context/end of life
Geriatric assessment based on
health/functional/social/environmental needs and
not only on allocation of resources
– Interdisciplinary for detection and mangement of
geriatric syndromes and chronic disease
– Intensive case-management
SIPA Intervention
Assessment and management
 Multidisciplinary team responsible for assessing needs, organizing
and delivering most of health and social services in community in
collaboration with primary care physician
 Comprehensive geriatric assessment on entry
 Evidence based interdisciplinary protocols
– Initial assessment, Nutrition, falls, CHF, dementia, depression, medication,
vaccination
 Rapid communication and mobilisation of resources
– Intensive home care, group homes
 24 hour nurse on call with MD backup
Beland, Bergman, Lebel, Clarfield et al: A System of Integrated Care for Older Persons With Disabilities in Canada:
Results From a Randomized Controlled Trial. Journal of Gerontology: med sciences 2006
SIPA Intervention
Case Management
Consolidated case management with
multidisciplinary team
Intervention with patients and caregivers
Liaison with family MD and specialists
Maintain clinical responsibility
Actively followed patients throughout
trajectory of care including in hospital
– Assure continuity
– Ease transitions
Principal SIPA Impact
 ↓ utilization of hospital and SNH utilization in SIPA group
– As expressed by the ↓ combined costs of hospital and SNH
– Driven by decreased ALC “admission”; ↓ N.S. differences in utilization in
other areas such as ED
 ↓ hospital utilization for those with increased ADL disability
 ↓ use of hospital as conduit for SNH placement
 Delaying SNH placement for those with few chronic diseases
(lesser risk) and those living alone (higher risk)
 Cost neutral
Beland, Bergman, Lebel, Clarfield et al: A System of Integrated Care for Older
Persons With Disabilities in Canada: Results From a Randomized Controlled Trial.
Journal of Gerontology: med sciences 2006
Major trials on integrated care:
Results
Major (yet incomplete) innovations and
transformations in clinical model and management of
care with modest addition of resources
Feasibility/impact of clinical/utilisation responsibility
The potential to change the configuration of utilization
of services with at least no increase in over all costs
While maintaining or improving quality and
satisfaction
For those older persons with moderate/severe
disability of the population who need a complex
combination of health and social services
Beyond the Models
Reflections on key elements
Primary Care
Integration et coordination
Coordination with specialty care
Governance/Incentives
Older person/family/community
Beyond the Models
Reflections on key elements
Primary care
What seems to work/needs to be tested
What does not seem to work
 Primary med care:
 Primary med care: organization
org/infrastructure/remuneration
/infrastructure/remuneration not
suited to complex continuing care
 The multi disciplinary care
integrated into primary medical  The programmatic, budgetary and
care
geographic cleavage between
 Evolution of relationships among primary medical and
multidisciplinary care
professionals
 Parallel play among professionals
 Rapid/flexible response and
accessibility
 Sporadic responsibility
 Rapid access to intensive
 There are no emergencies
professional services
(professional and social); access
to a wide range of
assisted/supportive housing
 Population data/ responsibility
Beyond the Models
Reflections on key elements
Integration/Coordination
What seems to work/needs to be
tested
 Integration/coordination based
upon clinical objectives in
primary care
 Geriatric
evaluation/intervention based
on health, social, environmental
needs as well as allocation of
services
– Management of chronic diseases
and geriatric syndromes
– Secondary prevention/early
intervention: mobility, falls,
dementia etc
What does not seem to work
 Coordination as an objective in
itself objective
 coordination based on the
existing way of doing things;
 evaluation principally to allocate
services/budget
 Coordination detached from
primary medical care
Beyond the Models
Reflections on key elements
coordination with specialty care
What seems to work/needs to be
tested
 Primary medical care closely
coordinated with specialty
services, in particular geriatrics
 Rapid access between primary
care and specialty/diagnostic
services/hospital
 Community geriatric
consultation and management
 Geriatric evaluation before
placement
What does not seem to work
 Episodic hospital restricted
geriatric evaluation and
consultation
 Complicated Access between
specialty services and primary
care
 ER as entry point
Implementation in a coherent system: challenges to explore
Specialised geriatric medicine programs
Beyond the traditional hospital role
– Optimise acute care for older persons on all wards; acute
geriatrics programs for targeted patients
– reorientation
– Sub acute and Rehab
– Research/teaching/training
The development of a new vision of hospital based
geriatrics open to the community
– Regional geriatric programs
– Community geriatric assessment teams
Beyond the Models
Reflections on key elements
governance/incentives
What seems to work/needs to be tested
 Governance, appropriate budget
incentives based on partnership,
joint planning and even joint
financing which support clinical
objectives
 Clinician leadership at clinical
and administrative level
 Entrepreneurial management
based on objectives: quality,
results and accountability
 Accountability based on
systemic markers: health and
functional status; utilisation
throughout the trajectory of care
What does not seem to work
 Pretend that incentives and
budget are not important
 Fragmented responsibility
 Accountability based on the
number of acts/hours
 Control top down management
Beyond the Models
Reflections on key elements
Older person/family/community
What seems to work/needs
to be tested
 Dignity, independence,
empowerment
 Choice
 Caring for the caregiver
 Engaging patient, family
and community
What does not seem to work
 Forget that patients and families
are intelligent and devoted
The Challenge of Change
 A vision for change based on emerging local
and national solutions, on evidence and on
international experience
 Adapt; do not adopt
 Partnership: clinicians, managers, researchers,
the community
 Role of research:
– Synthesising evidence
– Population and practice based studies
– Evaluative research