The pathway for the elderly from 75 years old and above: experimental implementation and evaluation of an integrated model care in France

Abstract

In the context of an ageing population and very fragmented health and social care systems, the French ministry of Health is testing a national program (“PAERPA : Personnes Agées en Risque de Perte d’Autonomie”) since 2013. The program experiments an optimal geriatric care management to prevent elders loss of independence. The first phase of the program including 9 pilot territories is subject to a contrafactual evaluation over a period of time (2015-2017) that allows exploring its effects. Objectives: The PAERPA is carried out by regional agencies of France which intend to improve the coordination of inpatient, outpatient and social care at a territorial level. Its objectives are based on the organizational and technological innovations around three items: avoid breaks elderly care pathways,improving the quality of life of elderly people and their caregivers, adapt the professional practices to the healthcare pathway of elderly people (to avoid silos). The program targets the elderly people from 75 years old and above and fragile populations (about 10% of the population of France), integrating providers of health and social care. Highlights: Innovation:The PAERPA sets out the establishment of governance structures, the development of new services & care pathways (e.i. The night nurse, Temporary housing service) and new ways of working (e.i. new roles including case management), the development of a multidisciplinary teamwork by creating of a local clinical coordination. All this has helped to transform the coordination devices. Impacts&outcomes: results on data from the first two years of Paerpa (2015, 2016) does not allow to establish a significant effect on any of the outcome indicators when all pilots evaluated together. However, we detect a significant improvement in some pilots on the outcomes the most sensitive to the primary care organization, such as polypharmacy and emergency visits. These results crossed with the results from qualitative analyses and progress made in pilots in implementing different tools suggest that the difference in experience between territories can be a determining factor. The first results of the qualitative and quantitative analyzes, and the feedback of the other 9 territories (involved since 2016), show that such a program can be deployed in a heterogeneous way depending on the territories and that the projects must be adapted according to the contexts and the history of the territories. The model could be applied to other different programs that involve issues on the coordination and cooperation of actors at the territorial level (e.i. projects on mental health). Conclusion: The evaluation informs the implementation of integrated care for older persons, and supports establishment of a new level of coordination and cooperation as the country seeks to re-design health service delivery. Lessons: This program identifies key lessons for an international audience interested in understanding of the challenges implementing complex service delivery change. Limitations: A flexible approach allows for an appropriate response to each territory, but limits the generalization of results. It is necessary to develop mixed qualitative and quantitative approaches to evaluate the factors of success and failure in pilot projects.

Keywords

• frailty
• pathways
• elderly people
• evaluation
• local coordination