PRIMARY CARE AND CARE FOR THE OLDER PERSONS

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Primary Care and Care for the Older Persons - framework

Primary Care and Care for the Older Persons - framework

Draft 100714

Introduction ½ - 1 page

In many populations the number of the old people is increasing. For Europe the proportion of people aged 65 years and older is projected to grow from just under 15% (in 2000) to 23.5% by 2030, while the proportion of those aged 80 years and over is expected to more than double (from 3% in 2000 to 6.4% in 2030) (Kinsella and Philips, 2005) However, the pace of aging in Europe differs considerably between countries. Turkey and Ireland have the lowest proportion of people over 65 years of age (respectively 6 and 11 %), Germany and Italy have the highest proportion (approximately 20 %) ^¹. In all countries these percentages are higher for females than for males and they are increasing. Partially, that is the result of increasing longevity : currently, at the age of 65, females have a life expectancy of 15 (Turkey) to 22 (Spain) years. For males these figures are respectively 13 (Slovak Republic and Hungary) and 18 (Switzerland) years.

The likelihood of developing a potentially disabling condition rises with increasing age and older people often suffer from multiple chronic diseases with impending disability and loss of independence. Despite the fact that some authors state that healthy ageing is lagging behind, with older people spending more and more of their years in ill health,(references) there is some evidence supporting the “compression of morbidity” thesis (Fries,1983) which suggests that, as populations adopt healthier lifestyles and therapeutic advances continue, the period of illness that individuals experience before death is compressed (Parker and Thorslund, 2007, Freedman 2002). Our perspective is not that of a doom scenario, with unlimited populations of inactive, dependent and ill elderly. Aging of our societies should be considered as progress and as a success and older people can be seen as a resource to society rather than as a cost.

Either way, because of changing demographics we will undeniably be caring for an increasing number of older persons. This provokes a series of challenges that require effective policy and practice.

In many European countries hopes are on Primary Care for the delivery of health services to the older persons^². Where they are well developed, the community orientation and multidisciplinary teams in Primary Care constitute a link with social services and a resource for prevention and support, early recognition and management of disease. A such they are best placed to provide integrated, coordinated care for complex patients with changing needs. At the end of life, palliative care is provided as well. Primary Care offers quality care against limited costs. While in Europe convergence takes place of role and functions of Primary Care, the organisation, structure and funding base varies widely between countries. Also, some countries have developed a strong and coherent Primary Care system whereas others are less oriented towards the community and more to hospitals. No country however can claim to have a Primary Care system that is sufficiently robust to adequately address all the challenges it meets – including the adequate provision of care for the older persons. Primary Care reform is ongoing in many countries. It is the diversity and reform of Primary Care that makes international studies and comparison rewarding.

In order to show examples of reform and the benefits of Primary Care and as an inspiration to policy makers, practitioners and researchers across Europe, this Position Paper provides an overview of the needs of older people and the responses of Primary Care services. Good policies and practices as well as innovations are highlighted. This Position Paper does not claim encyclopaedic completeness, it rather aims to show variety and diversity. Because each approach is highly dependent on context, the organizational examples often provide little understanding about the critical factors for success or failure in a specific setting. The differing contexts in which people work require that solutions be tailored to national circumstances.

This Position Paper has been developed in 2010 through a Medline search and an expert consultation process which has been designed by the European Forum for Primary Care^³. It is one of a series of Position Papers that is being published since 2005.

Definition of terms ½ - 1 page

Primary Care

In this Paper, we make no distinction between Primary Care and Primary Health Care (PHC).

As mentioned above, PHC is not a fixed organisational structure or level of care, that can be easily and unambiguously identified. Instead, it is considered as a combination of essential characteristics on the basis of the core values of equity, solidarity and social justice, that are promoted by the PHC movement since more than 30 years:

Care that is easily accessible – in the community, without financial or physical (distance) barriers.
Long term personal relationship and continuity of care – person oriented care and not disease or organ oriented care. This implies attention for functioning and independent living of people.
Comprehensive and quality care, implying evidence based generalist care for all common health problems. It includes a collaboration with specialist services where generalist services are insufficient.
Responsibility for the health of people in their community, which implies attention for determinants of ill-health and social aspects.
People are partners in managing their own health.

PHC does not emerge spontaneously, it requires a constant effort and well planned design to ensure performing PHC. According to the World Health Report of 2008^⁴ most countries would benefit from four major reforms:

Universal coverage reforms, to improve health equity;
Service delivery reforms, to make health systems people-centred and of high medical quality.
Leadership reforms, to ensure the development of coherent health systems;
Public policy reforms, to promote the collaboration between public health and primary care, addressing the health of communities as well as individuals.

The older persons

Who are the older persons? Neither the World Health Organisation nor the United Nations has a standard numeric definition but the – arbitrary – definition used in Europe is people of over 65 years of age. In this Paper we use this same definition, although the age limit may change in the coming years.

Specific needs of elderly 2-3 page

Aging is associated with rising levels of multimorbidity and dependency and the older population accounts for most costs in health services. Traditionally, health needs are defined on the basis of health consumption information and on morbidity and mortality data. Very frail people aged 80 years and over are major users of informal care and health and social services (Audit commission 2000, Hellstrom and Hallberg 2001). Yet they are a heterogeneous group with heterogeneous needs which creates important challenges to healthcare providers (Byles,2000) and healthsystems. In the following paragraphs we try to offer a wide view on the needs and challenges to care for older persons.

CLINICAL NEEDS

A.1. The epidemic of chronic disease

Primary Care meets with a range of health problems of older persons. Chronic diseases such as depression, dementia, Parkinson’s disease, Cardiovascular Disease, COPD are not specific for, but more common, in this age group. We discuss a number of these conditions and describe specific approaches in several countries on offering primary care.

Eg. Parkinson/Dementia/Depression/Diabetes/Chronic Heart Failure/ COPD/stroke/falls/mental health...

“Black boxes”

Most strategies for the care of chronic conditions are disease specific. These recommendations are based, where possible, on evidence based clinical trials which often result in single disease management programs. However, patients with multimorbidity may have different needs. There is widespread consensus that actual healthcare delivery may not correspond to the needs of patients with multimorbidity and that healthcare management in multimorbidity is one of the most important challenges for the future.

A.2.Multimorbidity

A.2.1. Epidemic of multimorbidity

In the ageing population the prevalence of multimorbidity increases gradually. Van Weel et al stated that 25-50% of people with a chronic disease have comorbid diseases. (Van Weel and Schellevis 2006). Epidemiologic findings on multimorbidity are not consistent and dependent on datasources, age groups and definitions used for multimorbidity. A review by Marengoni of 33 population based studies published between 1989 and 2007 defined prevalence rates ranging from 21-89%. Another review by Fortin et al described rates of multimorbidity between 50-100%. Specific for the older people (aged over 65) Anderson et al found that 48% have 3 or more chronic conditions and 21% have more than five (Anderson 2002).

A.2.2 Impact of multimorbidity

Growing morbidity does not always imply concurrent disability, since diagnostic and therapeutic strategies have improved (Christensen 2009). Multimorbidity is supposed to be associated with poor quality of life, physical disability, high healthcare utilization and mortality and this association has been proved by Gijsen et al. Moreover the authors described less preventive care, lower intensity of treatment for certain conditions, less attention to psychiatric comorbidity, greater numbers of hospitalization and outpatient visits and overall higher healthcare costst. (Gijsen 2001). However, evidence is only marginal and multimorbidity is a complex phenomenon with an almost endless number of possible disease combinations with unclear implications. To manage multimorbidity in the future we have to assess the impact of the problem in detail to be able to focus strategies in clinical management and health care organization to the patient’s individual needs.

A.2.3 Clinical challenges in multimorbidity

Clinical practice guidelines are being developed to improve quality of health care. Being disease specific in set up, they overlook the reality of multimorbidity (Boyd CM 2005). For example obtaining exercise to promote health in diabetes or COPD may be complicated by pain by osteoartritis or lack of motivation caused by depression. Theoretically, individuals with multiple conditions face polypharmacia, fragmentation of care, competing or conflicting guidelines, and inattention to their own preferences and concerns (Ritchie 2007) . Therefore, in daily practice guidelines are questioned and modified based on the context of the patient. Comorbid diseases, patient preferences, functional status, quality of life, life expectancy and environmental factors will be of influence. It is clear that managing multimorbidity, is much more than simply the sum of separate guidelines (Van Weel and Schellevis 2006). There is a need to develop strategies for the inclusion of the clinical and practical aspects of multimorbidity in clinical practice guidelines.

A.2.4 Organizational challenges in multimorbidity

Multimorbidity seems to be associated with high health care ultilization. At this moment, the availability of disease-specific clinical guidelines, seems to lead to the implementation of chronic disease management programs that should improve quality of care for individual chronic diseases. However, this strategy is not always comprehensively integrated in the existing healthcare system and requires an increasing amount of additional resources. For the individual with multimorbidity the multiple disease management programs increase the complexity and load of care. To use future health care resources in the most efficient way we need a clear assessment of the clinical needs of patients with multimorbidity. Developing measures of the quality of care needed by patients with multimorbidity is critical to improving their care (Boyd CM 2005).

A.2.5 Paradigmashift in multimorbidity

To define measures of the quality of care needed by patients with multimorbidity we should cross the borders of individual diseases. We need a comprehensive approach, beyond traditional biomedical parameters (outcomes for single diseases), with the focus on generic outcome measures such as functional status and quality of life. The eventual purpose is to adapt delivered health care to the individual’s specific needs and goals. This perspective is in line with the paradigm shift from problem oriented to goal oriented care (Mold 1991) . An important challenge is the variability in needs of the complex patient

A.2.6 Primary care to tackle multimorbidity

The central medical professional for the care and management of multiple chronic diseases is the GP. This is related to his broad expertise but also to the usually longstanding relationship with older patients.

How to offer appropriate care to elderly with co-morbidity is the focus of many programmes and projects in Europe.

A.3 Frailty

Little is known regarding the proportion at risk for functional decline. Health indicators based on selected chronic conditions or risk factors are difficult to interpret because multiple combinations of degenerative diseases result in considerable heterogeneity in the risk for functional loss and health care needs. Frailty is likely to be a precursor of disability. Frailty is a state of increased vulnerability to adverse outcomes. It is a syndrome that results from a multisystem reduction in reserve capacity to the extent that a number of physiological systems approach or cross the threshold of symptomatic clinical failure. The frail older patient has a declining reserve capacity for dealing with stressors. As frailty leads to recurrent hospitalization (Fried, 2001), institutionalization (Bandeen Roche 2006) and death (Fried, 2001, Bandeen roche 2006, Fugate Woods, 2005, Ensrud, 2007; Ensrud 2008; Cawthon 2007), prevention and where possible treatment of frailty should be high on the medical agenda. Because frailty appears to be a dynamic and also potentially reversible process, early recognition of frailty and early interventions should be important issues for family medicine.

However a major impediment to measuring frailty in population based surveys, is the lack of an operational definition. Fried et al (2001) defined a frailty phenotype in which weakness, tiredness, poor endurance, weight loss, low levels of activity and slow gait speed were defined as core elements. (Three or more features indicate frailty, 1 or 2 indicate prefrailty, and none denotes frailty)

On the basis of US studies it appears that frailty affects about 7% of people aged 65 years or older and about 25-40% of those aged 80 or older (Fried 2001 uit ref 32 PB). A meta-analysis from Santos-Eggiman et al (2009) estimated that in ten European countries frailty affects about 17 % of patients older than 65 with higher proportions in southern than in northern Europe. Although demographic characteristics did not explain international differences in frailty they found a strong relationship between education and frailty and an attenuation of country effects after adjusting for this factor. This illustrates the need of a biopsychosocial approach which integrates nonmedical factors. Because we are still organ and disease focused both frailty as a syndrome and the vulnerability that underpins it can be easily overlooked. Frailty does not fit into an organ- or disease focused understanding of patients because there is almost never a chief complaint and the features of frailty occur in combination. Frailty provides a conceptual basis for moving away from organ and disease based medical approaches toward a health based integrative approach and therefore fits the biopsychosocial model of generalism very well. Family physicians already use the concept of frailty to aid clinical decision making, assess risk factors and complications, evaluate interventions and predict outcomes because it is a better measure than chronological age.

A.4 Loss of independence

Between ... and ... % of the population above 65 lives in an institution – hospital, nursing or long term care home or in an institute for rehabilitation. Above 75 years, this has increased to ...% . Is the increase in life expectancy we observe, accompanied by a concurrent postponement of functional limitations and disability or will we face an interminable group of patients with high disability rates? Several studies have suggested that disability in general has declined, however it remains unclear whether such improvements extend to all types of difficulties and all groups.(Freedman et al). Bandinelli et al state that despite declining age-specific disability rates (Fries, 2003), the aging of the population is expanding the prevalence of disability and increasing the burden on medical and social services (Guralnik, 2002). Notwithstanding that most older people retain high levels of independence and make substantial contributions to society, there are clear age related support needs. Australian figures indicate that while only one in 20 of those aged 65-69 require assistance with self care activities, this rises to one in three among those aged 80 years and over. (Australian Institute of Health and Welfare). What and how much health and social care a person needs is entirely determined by their health, physical, cognitive and social function. Almost always it is a deterioration in health that leads to a decline in a person’s abilities. In turn, ability, personality, mental health and the extent to which a person has friends and family available to help them determines how much and what sort of formal care services they need (ref) . Living with another person often provides much ongoing volunteer or family support that helps people remain as independent as possible for as long as possible. In addition to family and volunteer support many older people use community services to help them remain independent. Community based services are needed to help older adults manage chronic illness while maintaining independence, remain connected while getting assistance and maximize their self care abilities. Frail older adults usually have multiple impairments and function best in environments they know. Since each move to a new setting may cause physical decline and depression we should guard it unacceptable that patients must give up their independence, to receive services they need, to remain as active as possible. (Rantz et al, ref 103)

A.5 Prevention and early detection

Health promotion interventions in later life require a different focus than those at younger

ages, with an emphasis on reducing age-associated morbidity and disability and the effects

of cumulative disease co-morbidities. Even a small reduction of disability may translate into large health care savings and improvements in the physical, emotional and social health of older persons.

There is a growing body of evidence to suggest that the modification of risk factors for disease even late in life can have health benefits for the individual; longer life, increased of maintained levels of functional ability, disease prevention and an improved sense of well being. Integrated services for older people aimed at promoting good health and quality of life and to prevent or delay frailty and disability can have significant benefits for the individual and the society. ( NHS NSF older people).

Black boxes?

Prevention of falls is a domain that borders primary care and has gained wide interest because it has shown to be effective.

PEOPLE’s NEEDS

In recent years, research has shown that the experience and perspective of the older people themselves may not show the same needs as identified by professionals. Hellstrom and Hallberg (2001) argued that older people’s perception of the influence of care in their life provides information about the type of care needed and the reasons the care is needed to support independence and maximize their quality of life. However, to tailor research and service development adequately, several perspectives are required, among others those of patients, families or social support networks, clinicians delivering care, third party payers and healthcare systems.

B.1 Patients’ perspectives

Rather than making assumptions we should listen to what patients want and need (both in research and practice). Qualitative studies (Themessl-Hiber, Bayliss et al, Potter at al) defining patients’ perspectives regarding the use of healthcare services defined following themes. Overall patients expressed a great appreciation of services without appearing to expect significant changes to their health status. One patient said “There’s not much you can do, other than that what they’re doing”(Themessl-Hiber). Patients especially valued face to face, personalized and flexible appointments. They valued continuity and want to see healthcare professionals they know and trust. Having a face to face appointment is important to ensure care is tailored to the individual (sometimes this will mean a home visit). They valued professionals working together to ensure that the appropriate package of services comes together. Being informed about every stage in the care process was also greatly appreciated. Patients defined both personal thresholds and personal opportunities in exploiting optimal care (Potter). Loss of mobility posed most difficulties both in daily life (people feeling stranded, unable to pursue daily routines and socialize) and in the utilization of optimal care (a lack of transport can prevent them from going to a GP surgery)(Potter, Themessl-Hiber, Bayliss). The problem of underutilization of certain services was especially explained by three tresholds (1) the services offered did not cater for their needs (2) their own frailties impeded them from enjoying the activities offered by the services and (3) lack of service flexibility. People want the timing and kind of care to be tailored and coordinated with their individual circumstances. People sometimes cancelled services because their timing or remit conflicted with their routines and habits (Themessl-Hiber).

Patient involvement and empowerment were seen as a great opportunity to optimize care. Patients describe the care of their conditions as a daily routine that is modified by their own perceived needs, physical abilities and sources of support. This routine included various self management tasks as well as an ongoing process of assessing symptom priorities and making personal treatment decisions. Although these processes were often time consuming, most respondents worked hard to maintain outside interests. Several respondents defined themselves as caregivers to others (usually a spouse) in addition to managing their own care. All provided detailed prescriptions of the effect that management of their chronic conditions had on daily activities and their interactions with the health care system. Participants felt that they knew their own needs well and wanted to be heard and acknowledged in their interactions with providers(Bayliss). Patients influence in the decision making process, for example in relation to the activities offered by services and the discussion leading to hospital admission or subsequent discharge were greatly appreciated (Themessl-Hiber). Patients describe ideal care as patient centered and individualized with convenient access to providers (telephone, internet, in person), clear communication of individualized care plans, support from a single coordinator of care who could help patients prioritize the competing demands from their multiple conditions and continuity of relationships. Participants wanted clinicians to appreciate the fluctuating nature of their medical needs and to have a caring attitude. Although they may not always need the same intensity of support, it must be continuous and not intermittent (Bayliss) . They favour an approach that supports and boosts their capacities, capabilities and social networks and a service that makes them feel safe while remaining inconspicuous when not needed and that ensures easily accessible help in emergency situations. Consequently, services like CA’s are highly regarded by older people. They are appreciated for raising confidence about being at home.” help is at hand at all times” (Themessl-Hiber). The will to retain control in the own home is prominent in patients’ expectations. The home is generally perceived as being the last area over which people are to assert control. In this same area elderly report the importance of the fact that any healthcare worker entering an older person’s home must respect the way they like things to be done, including the use of their belongings. Another aspiration is the importance of company and being listened to : older people can feel lonely or isolated. Contact with health and care workers can offer a much needed form of interaction and friendly conversation is often welcome. A last aspiration at the community level is the need of proactive healthcare and support. Older people are often unaware of what is available to them and may need help and support to understand and access services. Information, advice and outreach are the bedrock to making this work (Potter). Most of the desired alterations focused on the process rather than the content of care. This observation is particularly important in designing future interventions to improve care for this population as current guidelines for chronic disease care (and associated measures that quantify quality of care) are based almost exclusively on the content of that care rather than the process. Bayliss et al concluded that the system desired is a labor intensive proposition for the healthcare system which creates a tension between the desire to provide such care and the magnitude of both the care needs and the size of the population. There is a need to develop systems to help us determine which patients needs what sort of support at which times, there is a major call for investigation into the size and characteristics of populations most likely to benefit from more intensive care coordination.

B.2 Workforces’ perspectives

B.2.1 Informal care

The interest in informal caregivers and their efforts concerned with the care and nursing of older people is because of many factors. The relatives’ effort to help is, according to Svedberg (2001), important for civilized society’s social capital where trusting relationships are essential. The ability to help and support others in their nursing needs can be important for the individual and can be a manifestation of relationships between people. The increasing responsibility placed on relatives today can, however be an indication of the increasing gap between the available resources and the needs of the older people. According to several studies, relatives seek improved information and better communication with the staff. Furthermore relatives need to be able to help and support their family members in accordance with their own requirements and conditions. This can be related to the fact that several studies show that caregivers can find the relatives demanding, but sometimes the relatives can be an undervalued resource for the older people from the caregivers’ perspective. The relationship between the relatives and the caregivers is seldom conflict-free which means that conflicts can arise in nursing situations. A study of Haggstrom et al (ref 135) showed that relatives of patients in special housing facilities find it important to trust caregivers (at the level of competence, accommodation and time for the patient). The relatives’ feelings regarding their participation in the care emerged . In the light of cut downs in resources they feel a heavy responsibility for the older people but they refuse to take over more care than they themselves want to. They felt that the present trend in society seems to expect more responsibility from family members. The relatives need more support and new opportunities in their participation in care.

B.2.2 Formal care

The necessary shift from hospital care to community care and primary care for the ageing population has changed both the content and process of care and has increased expectations. Home care is of growing importance. In a study of Carlisle et al (UK-1997), it was reported that GP’s could consider changes in community care as a problem because their workload increased as a result. A more recent study (Modin et al, Sweden, 2009) investigated the position of the GP in a primary care model where district nurses provide home care for old persons with a mixture of chronic disease, symptoms and functional disability. This study was conducted after the observation that those patients were less often seen by GP’s than other patients of comparable age (modin, 2002). By the mean of qualitative interviewing the study identified the main concern of GP’s which is to stay in charge of medical treatment. The problematic of the patients followed by DNs was complex and knowing how to handle this was difficult. In addition, the patient’s personal ability to cooperate, decide and adhere was often decreased. In much of this the GP had to rely on others. Despite the fact that close collaboration with other healthcare workers is not always uncomplicated the GP’s in this study expressed feeling satisfied with the collaboration with DNs. In complex patients GP’s have to be ready to continuously change the goal of the treatment. The GP’s basis for evaluation and diagnosis was to a large extent dependent on the information of the DN and other home care providers. Despite the fact that the “managed care model with DMs” is context specific and therefore not easily extrapolated to other contexts, these results point the need to focus on the process of collaboration in home care between the GP and other care providers. The above results explore the situation from the GP’s point of view. As there are many actors involved it would be of interest to explore it from the view of the patient.

B.3 Health systems’ perspectives

As unscheduled admissions have been described to be among the most important pressures on healthcare systems (Kendrick and Conway, 2003) a main attempt is to avoid or shorten hospitalisation, by preventing or mitigating disease and offering home based care. Current healthcare systems are largely built on an acute episodic model of care which is ill equipped to meet the long term and fluctuating needs of older people with complex chronic health problems. The mismatch between the needs of the population for proactive, integrated and preventive care for chronic conditions and a healthcare system where the balance of resources is aimed at specialized episodic care for acute conditions might be one of the reasons of the current rise in hospital admissions (Scottisch Executive, 2005).

In order to provide better support for the patients there is a pressing need to bridge the boundaries between professions, providers and institutions trough the development of more integrated and coordinated approaches to service delivery. In this was new models of service delivery are designed to achieve better coordination of services across the continuum of care. Although this has a logical appeal the evidence on the effectiveness of different forms of integration and coordination remains uncertain. There is sufficient evidence that single or multiple components of models such as the Chronic Care Model ((CCM) developed by Wagner in 1999) improve quality of care, clinical outcomes and healthcare resource use however it remains unclear to whether this applies to the model as a whole or whether the same benefits can be achieved by using parts of the models.

A more fundamental problem is the lack of common definitions of underlying concepts. Integration and coordination have been pursued in many ways in different health systems and there is a plethora of terminologies (“integrated care” “coordinated care” collaborative care” “managed care” “disease management” “person centred care”). This confusion very much reflects the polymorphous nature of a concept that is applied from several disciplinary and professional perspectives and is associated with diverse objectives.(Caring for people with chronic conditions, a health system perspective)

ORGANISATIONAL NEEDS

Frailty and dependence come with age. Remaining independent often depends on health and social sevices being effective enough to support people. In most countries in Europe, policies are emerging to slow down dependence and help people to live at home as long as possible. Services and interventions should meet the care needs of older people, to avoid the danger of negatively affecting care and minimize refusal and dissipation of offered services (Littlechild and Glasby, 2000)

A model rooted in primary care

Continuity and coordination of care are particularly important for older patients as they are apt to have multiple medical problems treated by several clinicians. Continuity and coordination of care have several components including a longitudinal relationship with a single identifiable provider and cooperation between providers and between venues of care. (Meijer, ref 3 uit ref 114) Coordination involves the “availability of information about prior problems and services and the recognition of that information as it bears on the needs for current care” (Barbara Starfield, ref 4 uit ref 114). Continuity of care is often equated with having a primary care physician. Several studies demonstrated associations between physician-patient continuity and satisfaction, reduced utilization, increased efficiency and better preventive care (ref 6, en 7 uit 114). A structured literature review by Saultz et al that evaluated 22 studies including 4 cinical trials found that “interpersonal continuity” was related to higher satisfaction, lower utilization and generally higher care quality (ref 8 uit 114) although one study found interpersonal continuity to be associated with higher pharmacy and referral costs. (Hjortdal, 1991-ref 10 uit 114). However, the coordinating care function for primary care physicians may become so burdensome that it will interfere with actually taking care of patients (Volpintesta Edward ref 87) . Nonphysicians such as case managers or multidimensional interventions sometimes provide continuity and coordination. Most interventions reduce utilization, however the multiple dimensions of those interventions are uneasy to distangle and are often not tested outside research settings.(Ref 114-identification of quality indicators, RAND method, not including patient factors or costs, based on literature review and expert opinions-eventueel deze lijst mee te nemen in de PP?)

Maintenance of good health – prevention – away from pessimism (they are old anyway).

A pessimistic approach to ageing and older patients might lead to impeding the promotion of health and active life in older age.

A pessimistic approach to ageing and older patients might lead to unfair access to services. Decisions about access to treatment and care should be made on the basis of each individual’s health needs and not their age. For example, even very complex treatments, if used appropriately, can benefit older people and should not be denied solely on the basis of age (NHS national service framework for older people).

A pessimistic approach to ageing might lead to premature admission in hospitals of residential care settings. All older people who need hospital care should receive it. A new range of acute and rehabilitation services is necessary to bridge the gap between acute hospital and primary and community care. The aim of those services should be to promote faster recovery from illnesses, promote timely discharge, maximize rehabilitation opportunities and independent living. (NHS national service framework for older people).

Person-centered care

Person centered care needs to be supported by services that are organized to meet needs. Organizational structures should act to impede the provision of care coordinated around the needs of the older person with respect to their individuality, dignity and privacy. A proper assessment of the range and complexity of older people’s needs and prompt provision of care can improve and prolong people’s independence, reduce the need for emergency hospital admission and decrease the need for premature admission to a residential care setting. Service system failings can undermine older people’s confidence and their ability to remain independent. (NHS national service framework for older people).

Health services should ensure an integrated approach to service provision regardless of professional and organizational boundaries (integrated care). This might include the introduction of a single assessment process in health and social care to ensure that older people’s needs are assessed and evaluated fully.

Patient empowerment

Enable patients to make informed decisions through proper information about care across different care sectors.

Empower patients towards self management.

Opportunities

Challenges of providing such support to patients with multiple conditions or those with different ethnic or socio economic background.

Disease management programs

The goal of chronic care is not to cure but to enhance functional status, minimize distressing symptoms, prolong life through secondary prevention and enhance quality of life (Grumbach 2003). It is clear that these goals are unlikely to be accomplished by means of the traditional approach to healthcare that focuses on individual diseases. Despite the need for clear evidence based strategies and the usefulness of disease management programs for individual chronic diseases, those interventions always have to be evaluated within and weighed against the context and needs of the patient.

Coordinated care

One of the core attributes for primary care is the coordination of multiple entities of care beyond the primary care practice, that is, specialists, ancillary services, pharmacies, hospitals and home care agencies. Most definitions of “coordination of care” focus on information exchange among providers to ensure they all act toward a common goal. However, this focus is to narrow because an important part of coordination also takes place between providers and patients and their families.(T Bodenheimer, ref 108) The content of this task is both clinical as administrative. Despite its undeniable importance, the task of coordinating care is often performed in between visits. In fee-for-service payment systems it is not compensated for GP’s. Lack of physician time and lack of payment are 2 likely explanations for suboptimal or inadequate coordination of care.

Integrated care

The application of the concept of integrated care to health and social care is not clear cut.

In many countries health and social care are managed by varying organisations and funded at different levels. Depending on the number of organisations concerned and their level of unconformity the perceived need for incentives to promote collaborative working and interdisciplinary arrangement might differ. Integrated care is often mentioned in those terms. Does integration of health and social care impact upon the operation of care management which is a key approach in providing coordinated care for vulnerable people? Do integrated structures have impacted upon patterns of professional working and underlying beliefs about roles? Challis et al (2006) (ref 154) concluded on the basis of a comparision of Northern Ireland and England that further investigation is required.

However, apart from organisational models for health and social care broader definitions have been used for the concept of integrated care. (Leichsenring, Groene and Garcia-Barbero, Niskanen, shorthell,...) The unifying denominator of integrated care concepts and approaches is their primary aim of improving outcomes for the target population, traditionally the frail elderly and other population groups with complex needs. Kodner and Spreeuwenberg (2002) defined the overall aim of integrated care as being “to enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex long term problems cutting across multiple services, providers and settings” (Caring for people with chronic conditions : a health system perspective)

Concept of integrated care – verder ontwikkeld in sommige landen, minder in andere, vraag aan experts, niet vooral UK maar andere landen

Palliative Care

Assessment methoden

Cave niet teveel ziektespecifieke benadering

Response by Primary Care 8-10 pages

In welke landen bestaat er een ouderenzorg beleid en wat is aandeel PHC daarin vraag voor experts

Transportation, local services and residential adaptation are addressed. Also in health, a wide array of policies and interventions has been developed, ranging from support to informal carers to geriatric assessments that pick up early signs and symptoms of cognitive or functional limitations. The role of home care, IT and domestic appliances and devices has gained importance – albeit there is a wide variation in their use.

We describe a number of approaches and services that have become mainstream. Further, we describe a series of new initiatives that may serve as inspiration.

Need for monitoring and assessments of health of the elderly – description of instruments that are used to monitor and assess – description of practices in different countries and results -

Need to support living independently - domestic appliances, home care, family care, housing;

Discussion on the role of primary care in this – examples from several countries in which primary care does play a role.

De tekst in dit blok is afkomstig van Ian Philp uit Sheffield, die we gaan benaderen als een van de experts:

The segmentation which I would propose is one which we used to develop national
policy for older people in England and was endorsed by the Prime Minister, Tony
Blair, at the time (personal communication).

The three groups are: frail, at-risk and the general population of older people.

The age cut-off for the general population of older people is debated. I would
use 60 plus as I believe this is the one used by the UN. At-risk and frail
older people are skewed to the older end within this general population.

For each segment one can explore a differentiated service response, by sector,
assessment methods, and key conditions.

Sector:

The acute hospital and long-term care sectors are focussed on the care of frail older people.
valt niet binnen scope van paper? Pauline: referenties over ontslag management
The primary care sector should do much more to identify and respond to health and care needs and prevention opportunities in the at-risk group.

A multi-sectoral approach is needed to maximise health and well-being in the general population of older people, through the promotion of exercise, good diet and social networks.

Assessment methods:

The evidence base is strong about the benefits of comprehensive geriatric assessment for frail older people. CGA utilises multidisciplinary specialist expertise.

Older people at-risk of loss of independence, health and well-being (because of the emergence of multiple age related health conditions) comprise about 50% of the 75 plus population, and are therefore too numerous for all to receive CGA, even in countries like the UK, Italy and the Netherlands where there are well-developed multidisciplinary geriatric services.

Nevertheless, holistic assessment is required, and can be delivered by a front-line professionals such as a community nurses as a basis for planning care and identifying those who need CGA. The Dutch EASY-care trail provides good evidence of the cost-effectiveness of this approach, using the EASY-care instruments which we developed in the 1990's in the SCOPE project, involving Hanneli, Giovanni and myself.

In the general population, postal survey methods using validated brief screening tools, can be used to identify the at-risk groups, who would benefit from holistic assessment.

Specific Conditions:

For each of the specific conditions mentioned in the background document, and
others, it can be helpful to segment by the three population groups. Niet teveel op ziektespecieke zaken ingaan – dementia + diabetes wel, verder vooral korte case descriptions

For example, in falls, there needs to be :
-a multi-sector strategy for increasing weight-bearing exercise in the general population of older people.

-a primary care response, including attention to vision, medicines, environment, exercise and bone health, to identify opportunities to reduce falls and fracture risk in the one in four people aged 65 plus who fall each year.

-referral to a multi-disciplinary falls and bone health service for those at greatest risk, such as those with a emergency hospital admission with a fall, a fall-related fragility fracture, or those with frequent falls.

If colleagues agree with this segmentation approach, our position paper could describe the rationale for a differentiated approach by sector, the evidence-base for the levels of assessment required for each segment and suggestions for appropriate responses for key conditions, with particular emphasis on the primary care role for each.

Maintenance of good health – prevention – away from pessimism (they are old anyway). How do primary care services deal with the question when to stop prevention (stop smoking, pressure to exercise) at advanced aged of the elderly. Examples from various countries.

How do primary care teams to adapt to provision of care to the elderly – team composition / relationship with geriatrics and other specialised services?

This is directly related to the diseases mentioned above ánd to multimorbidity

For example (1) how do primary care providers ensure compliance with multiple medicines prescriptions – link with pharmacy / home care / informal care / as part of primary care? (2) role and position of the geriatrician – in or outside primary care? (3)

Palliative care – in how far embedded in primary care – description of % of palliative care provided by GP’s and other primary care providers – in how far is this a specialised service.

(input from UK and Slovenia is particularly interesting).

International developments in self directed care. (ref 1-alakeson et al uit search PB). The program allows beneficiaries to manage their own budgets and choose services that met their care needs. Such developments have been observed in England, Germany and the Netherlands as a way of increasing patient centred care. Self directed care should allow consumers to meet specific individual needs and preferences to remain independent and in their own homes. Early results are promising however ... Cave : most vulnerable groups (need for a counselling service),; cave ; transfering a greater proportion of risk for unexpected health care needs to individuals. Cave : non-evidence-based care. Cave : privatisering

Vita Lesauskaite et al. Challenges and opportunities of health care for the aging community in lithanua. Gerontology,2006:52:40-44

Jones H et al. A Slovenian model of integrated care for older people can offer solutions for NHS services. Nursing times;105:49-50.

Obstacles to providing primary care for the elderly. 2-3 pages

Funding often is an obstacle to ensure well coordinated and integrated care – to give examples from various countries.

What policies do European countries have to strengthen or support primary care for elderly? 2 -3 pages

Overview of the countries that developed a general elderly care health policy and the place of primary care in that policy (Pim can do this chapter)

In how far do these policies address the obstacles mentioned above?
What priorities for primary care do these policies mention?

In many cases structural or funding issues contribute to the lack of cohesion and integration in the service system. Often a range of programs funded by different levels of government have been created. This often results in confusion for providers, referrers and clients, poor integration between services with difficulty in assessing information and navigating the system. However different levels of funding also have a positive side as it creates diversity of services and models of delivery and can enhance quality and availability for consumers as well as providing multiple funding sources for providers. The greatest challenge is to stretch limited resources through better integration, coordination and communication. (Anne Marie Fabri ref 77)

Integration, coordination and communication – bevoorrechte rol voor primary care?

Needs for research and further developments 2 pages

On perception by elderly themselves?

Strengthening country policies?

1 http://stats.oecd.org; data on 2008

2 Reference to a number of country policies, like UK, Netherlands, France, Slovenia etc

3 See www.euprimarycare.org

4 Primary Care: now more than ever. WHO 2008

10 ABSTRACT INTRODUCTION PRIMARY OPEN ANGLE GLAUCOMA (POAG) IS
15 HEALTH OUTCOMES FOLLOWING LIVER FUNCTION TESTING IN PRIMARY
20 FAMOUS SCIENTISTS S PRIMARY 7 ROOM 16

Tags: older persons, for older, persons, primary, older