Howard Bergman MD, FCFP, FRCPC
Chair, Department of Family MedicineProfessor 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 MedicineProfessor of Family Medicine, Medicine and OncologyThe Dr. Joseph Kaufmann Chair of Geriatric Medicine
McGill University
17.3.12
Family MedicineMédecine de famille
The Complexity of Care for Older Persons
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 personsHealth care systems poorly adapted to the management of
chronic disease, frailty and dependency; complexity of treating chronic diseases and frail older persons
16%(n=8)
30% (n=15)
42% (n=21)
12% (n=6)
0
20
40
60
80
100
Without frailtymarkers or IADL /
ADL disability
With frailtymarkers but
without IADL /ADL disability
IADL disabledwithout 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)
Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy- preliminary findings
Comorbidities ADL dependency
Frailty
MonitoringIntervention
médicaleMonitoring
Multidisciplinary care
MonitoringPrevention
Health promotion/prevention
ScreeningAcute care
Complex care
Focus on very frail older persons with disabilities
Generally over 75Disabilities in ADL/IADLAcute and chronic medical problemsImportance of social networkFrequent 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 carePresent difficulty in management
– Fragmentation; unmet needs; underutilization of effective geriatric and care management interventions; parallel play-medical, 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/CoordinationProjects
InternationalPace/On Lok (USA)S/HMO (USA)Bernabei (Italy)British experience-MatronsCOPA-Paris
CanadaCHOICERISCBois-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 approachA 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
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 entryEvidence 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
SIPA InterventionAssessment and management
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
Consolidated case management with multidisciplinary team
Intervention with patients and caregiversLiaison with family MD and specialistsMaintain clinical responsibilityActively followed patients throughout
trajectory of care including in hospital– Assure continuity– Ease transitions
SIPA InterventionCase Management
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 placementDelaying 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 responsibilityThe potential to change the configuration of utilization
of services with at least no increase in over all costsWhile maintaining or improving quality and
satisfactionFor those older persons with moderate/severe
disability of the population who need a complex combination of health and social services
Beyond the ModelsReflections on key elements
Primary CareIntegration et coordinationCoordination with specialty careGovernance/IncentivesOlder person/family/community
Beyond the ModelsReflections on key elements
Primary careWhat seems to work/needs to be testedPrimary med care:
org/infrastructure/remunerationThe multi disciplinary care
integrated into primary medical care
Evolution of relationships among professionals
Rapid/flexible response and accessibility
Rapid access to intensive professional services (professional and social); access to a wide range of assisted/supportive housing
Population data/ responsibility
What does not seem to workPrimary med care: organization
/infrastructure/remuneration not suited to complex continuing care
The programmatic, budgetary and geographic cleavage between primary medical and multidisciplinary care
Parallel play among professionalsSporadic responsibilityThere are no emergencies
Beyond the ModelsReflections 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 workCoordination as an objective in
itself objectivecoordination based on the
existing way of doing things; evaluation principally to allocate
services/budget Coordination detached from
primary medical care
Beyond the ModelsReflections 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 workEpisodic 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 exploreSpecialised 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 ModelsReflections on key elements
governance/incentivesWhat seems to work/needs to be testedGovernance, 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 workPretend that incentives and
budget are not importantFragmented responsibilityAccountability based on the
number of acts/hours Control top down management
Beyond the ModelsReflections on key elements
Older person/family/community
What seems to work/needs to be tested
Dignity, independence, empowerment
ChoiceCaring for the caregiverEngaging patient, family
and community
What does not seem to workForget 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
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