The Complexity of Care for Older Persons

1. 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

2. 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 Family Medicine Médecine de famille 17.3.12

3. 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

4. The Shifting Face of Health Care • ↑ Complexity • ↑ Interdependency • ↑ Uncertainty • Increasing preoccupation with costs and performance leading to increased government intervention/control/reform • Continuous Change

5. 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

6. 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

7. Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy- preliminary findings 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)

8. Health promotion/preventionScreeningAcute care Complex care Comorbidities ADL dependency Monitoring Intervention médicale Monitoring Multidisciplinary care Frailty MonitoringPrevention

9. 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

10. 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 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

11. Integration/CoordinationProjects International • Pace/On Lok (USA) • S/HMO (USA) • Bernabei (Italy) • British experience-Matrons • COPA-Paris Canada • CHOICE • RISC • Bois-Francs/PRISMA • SIPA

12. 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

13. 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

14. SIPA InterventionAssessment 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

15. SIPA InterventionCase 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

16. 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

17. 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

18. Beyond the ModelsReflections on key elements • Primary Care • Integration et coordination • Coordination with specialty care • Governance/Incentives • Older person/family/community

19. What seems to work/needs to be tested Primary med care: org/infrastructure/remuneration The 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 work Primary 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 professionals Sporadic responsibility There are no emergencies Beyond the ModelsReflections on key elementsPrimary care

20. 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 ModelsReflections on key elementsIntegration/Coordination

21. 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 Beyond the ModelsReflections on key elementscoordination with specialty care

22. 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

23. 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 ModelsReflections on key elements governance/incentives

24. 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 Beyond the ModelsReflections on key elementsOlder person/family/community

25. 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