National Clinical Programme for Older People
‘Transforming Care of Older People in Ireland’
26th May 2015
'Models of integrated care for
community-dwelling frail older people’
Lorna Roe
Centre for Health Policy and Management, Trinity College
Dublin
This work was funded by the HRB in Ireland under Grant No. PHD/2007/16
Irish supports for frail older people
•Myriad of services: GP ,Public Health Nurse, Older persons psychiatry ,
Ophthalmology, Home Help, Respite care, Carers Allowance *, Home Adaptation
Grant *, Free Travel Card *, Living Alone Allowance *, Fuel Allowance*,Household
Benefits *, Alzheimer's Society *,ALONE *,Day Care, Counsellor/ Psychological,
Occupational therapy, Chiropody, Social worker, Meals on wheels, Retirement
Group*, RESIDENTIAL CARE
• Numerous providers: by many sectors (public healthcare, private healthcare,
local authority, vol org) and different Government Departments and different
organisations and teams.
INFO OVERLOAD for the average Joe. 50% of older people go see their GP to get
information on services & 20% contact the HSE (Murphy 2012)
Yet:
•The HSE only delivers half of these services
•GPs report feeling unable to deal with such patient complexity
Murphy, C (2012) The distribution and determinants of home-based social care utilisation in older person: Irish and Comparative Perspectives
Integrated care??
• Organisational strategy
– Mental health /Homeless / CDM/ Frailty
– Within health sector only
– Health & other sectors
• Chief aim: to reduce undesirable outcomes through the better
coordination of care
• Impetus: demographic ageing + change in the nature of need among
older people toward increasing patient complexity requiring ‘complex
care’
Integrated care for frail older people.
Let’s scratch the surface...
•
What are models of integrated care?
•
What are others doing internationally?
•
How can we better understand our own care system?
•
•
What patterns of care are occurring within our care system
today?
What can we learn about coordinating care from the frail older
people?
1. Conceptualising integrated care?
Yet, coordination of services was noted in principle in The Care of
the Aged report in 1968, in the Years Ahead Report 1988 and
within the work of the NCAOP and later in strategies of ‘integrated
care’ in the 2000s.
Much conceptual over lap between ‘care coordination’ and
‘integrated care’ (Kodner 2002; McDonald et al, 2007) however integrated care
is a separate strategy involving:
•Comprehensive geriatric assessment
•Single entry point
•Case management
•Multidisciplinary team
•Financial incentives
•Electronic transfer of information
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2. What’s happening internationally?
Linkage
Coordinated
Integrated
• LinkAge Plus
UK
• Chains of
Care Finland
• Chains of
Care Sweden
• Program of Research to
Integrate the Services
for the Maintenance of
Autonomy (PRISMA)
Canada
• Hong Kong
• Vittorio Veneto, Italy
• Roverto, Italy
• Senior Care Options
USA
• Coordinating Care for
Older People (COPA)
France
• Social Health Maintenance
Organisation II (SHMO II) USA
• Program of All inclusive Care
for the Elderly (PACE) USA
• Systàme de services intégrés
pour personnes âgées en perte
d'autonomie (SIPA) Canada
• New York Visiting Nurse
Scheme (NY VNS) USA
• Coordinate Home Care Trial
Australia
• Illawarra, Australia
•
Buurtzorg
Netherlands
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Much good intent.. (But)
• The frail
– Who are the frail- no measurement tool identified
– Why is the model created for the frail
• Keep people out of hospital and/or nursing home
• Or improve quality of life?
• The intervention
–
–
–
–
Weak theoretical base: Who does what, where when, why?
Inadequate description of design and development
Inadequate description of processes
How can we understand the context of these interventions
3. What’s
happeningStudy
in on
3. The Irish
Longitudinal
Ageing our own care system
• Used a sub-sample of TILDA data identifying those frail aged
>65+ (n=756)
• Question: Are there patterns of care within the frail older
population across the ‘whole system of care’ in Ireland?
• Analytical Strategy: Latent Class Analysis to model unobserved
trends between 23 different services captured by TILDA.
– 23 services variables from the GP to hospital and community care.
Also created an informal care ‘service’ variable.
– 4 groups of people emerged from the LCA analysis
www.tilda.ie
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1. Low Users (50% of the frail)
– Low P of use across all services, 20% chance of carer, 0.02 P of seeing a
PHN!
– Mainly ‘younger old’, living with others, most don't drive
– just above FI threshold, approx 1/3rd MM, fell last year, disabled and
approx ½ worry about falling, 60% perceive health as poor.
2.
‘Well managed, considering’ (28% of the frail)
– 2nd highest P to use community services & 2nd lowest P to use
hospital services intensively.
– 58% chance of having an informal carer, 50% chance to see PHN, 42%
chance of above avg GP use
– ‘Very old’ women (<75years), half live alone, 66% cannot drive, 70%
disability but most barely above frailty threshold, 46% MM, lowest
prevalence of falls (25%) but second highest fear of falling (67%), 64%
perceive health as poor.
3, ‘Unsupported Hospital Users’ (19% of the frail)
– High P of an overnight hosp adm and an above avg length of stay, 33%
chance of carer, 50% chance of seeing GP intensively , 40% chance of
seeing a PHN, less than 20% chance of receiving community services
– No age or gender differences, 60% live with others, 57% still drive,
– Majority low FI score but majority (72%) perceive health as poor, 40%
fell and 62% fear falling, 48% MM and 43% Disability
4, ‘Throw Everything At Them’ (3% of the frail)
– 95% chance of PHN, 85% chance Informal carer, P<0.70 of above
average use of all hospital services but highest P of community
services
– No age differences, mainly female, 66% cannot drive, 86% poor
perception of health
– 67% v frail + MM, 62% fell last year and 80% fear falling, 95% disability
Preliminary thoughts
• Management of frailty in Ireland
– not a homogenous pattern of care within the health care system
– Unpacking & understanding these patterns
• Why do these patterns occur do the patterns matter in terms of
outcomes over time; QOL, service use, frailty score.
• The healthcare system: We know that frailty drives service
use (across all services) by comparison to pre frail and not frail
(Roe, 2015) and even multimorbidity (5+ chronic conditions) (McDaid,
2014) Yet...
– Very low P of use of community care across all the groups
– Notable increase for group 4 but does the system intervene too late?
(Ref; McDaid O (2014) ‘The Chronic Ills of Multimorbidity’ Doctoral thesis
Roe (2015) “The impact of frailty on health and social care utilisation in Ireland” Presentation to the IGS October, 2014)
4. Coordinating care
The experience from the community
The Older People Remaining At Home project
• AP funded project run by AFI in conjunction with HSE Services for
Older People. Consists of a model of IC:
– Support Coordinators to case manage approx 40 clients
– Local Steering Group
• Qualitative interviews exploring the process or action of
coordinating care and barriers or enablers to coordination
– 10 frail older people* in two sites **
– Two Support Coordinators***
– Data collected recently so the following are preliminary themes.
*Frailty defined and measured by Rockwoods Frailty Deficit using the Single Assessment Tool for Older People (Interrai
Home Care Assessment form) indicators which can be linked back to TILDA
** Sites in Donneybrook/Ranelagh in South Dublin and Skerries in North Dublin
*** In Donneybrook a Social Worker was seconded to the project, and a Public Health Nurse filled the role in Skerries
Hospital: A gateway to community
• Gentleman with a post operative disability and difficulty with
ADLs advised
– ‘you’d to admit him to hospital in order to get him into rehabilitation”
• Time and time again care in the home established after a visit
to hospital
– “who set up the home help from Beaumont? The girl in the, what is
she called? Discharge Nurse? ...She was in touch with the district nurse
here, nurse X. Yeah, and they had it organised for when I came home.”
Brokerage
Couple in their eighties, husband (an ex- Professor from a top Irish
university) has Parkinson's and early stage dementia and wife has back
problems.
• “what on earth is a Public Health Nurse, we don’t know what their role is
or what they do”
• Don’t know what they’re entitled to or what is around them locally to
help. Only received a disability parking disc through the OPRAH case
manager & that “opened the world back up to us”.
• Applied for a home help through the PHN in 2013, husband had a bad fall
again in January 2015 & it’s only now they get the help. Husband asked me
‘how long do you think we’ll get this for, is it more than a few weeks?”
– Home helps; pattern of applying, waiting, health crisis and hospital
stay, then home help.
Ongoing case management
Complicated by issues with trust, pride, independence...need to
slowly build up relationship and persist with suggestions.
“ She kept at me to go to the centre, I said ah, I said no, and then she
made me promise that I’d go for one day and just one day to see what
it was like...and I still didn’t do that..but she was going into a house
down the town (one day) and she met me coming out on the path and
asked me to go ...So I had to say yes I would, so I went that day centre
and I’m going since.
We do exercise and everything in it, that’s really helping me, yeah...I’m
able to kind of pull, put, fix my collars ...I wasn’t able to (before)... I’m
the whole day there and its great and I’ve met lovely people there.”
The work of linking services
• “God love him, the only thing he wanted me to do for him was get him a
lift to mass, because he used to drive to Mass every day and he wasn’t
driving. So anyway, I went to the priests and he said no, it’s too much of a
commitment. So I then actually went through somebody else and she got
him someone, and sure he was made up because he got to Mass every
Sunday... transport’s huge, it comes again and again and again..” (OPRAH
Case Manager/District Nurse)
• “But giving out the information, I suppose that’s been the biggest thing,
you know...a lot of the time as a community nurse as well, we’d give them
out the forms, you know, we give them out the forms for a grant, and that
was your job done as that was just as far as you could go. But now you
can, you can follow it up and you can do it with them, ask their
permission, if the family’s alright, if I follow up with this” (OPRAH Case
Manager/District Nurse)
Who’s captaining the ship?!!
– Fragmentation: Medics manage medical need and PHN manage social
care needs. Psycho social needs are left untreated.
– Management and monitoring: Older people have no idea when their
next appointment is or what their care plan might look like. Stress!
– Overall care: The care for these individuals is a complicated, delicate
model of care. Largely left to older people, their spouses and carers to
overall manage.
• Healthcare professionals may reschedule and create an avalanche
of phone calls to rearrange care. They describe being ‘always on
the go’ to appointments, and feeling exhausted.
• Many use old notebooks to try record everything.
Is that what we equate as ‘integrated care’??!!
Discussion &
Conclusion
1. What is your evidence base?
–
How to measure, assess and manage frailty? How to design good
models of care?
2. Do we have the components to facilitate an integrated
model?
–
Service levels in the community, the infrastructure to transfer of
information quickly and safely, new staff roles for case manament?
3. Should we incorporate a patient centred design to improve
coordination?
–
Can solutions come from older people themselves?
4. What are our goals
–
3 square meals a day and stay out of hospital VS managing complex
needs and improving Quality of Life.
Acknowledgements
Prof Charles Normand
Prof John Brown
Dr Aisling O’Halloran
TILDA participants for their ongoing
commitment to the project.
OPRAH participants for their warm
welcomed into their homes and
sharing their stories and tea!
Dr Arthur White
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