"Center of Geriatric Care" project- the development of the interdisciplinary home-based care model for elderly patients in Gdansk, Poland. Pilot study

Abstract

Introduction: Integrated care for elderly patients is not a standard in Central European Countries (CEC). Lack of coordination between healthcare service providers and social support, and diverse financing has led to low effectiveness of the whole care system for elderly. Short description of practice changes implemented: "Center of Geriatric Care" project assumes development of integrated model of care for elderly patients, managed by interdisciplinary geriatric team. The essential aims are: to develop an effective, coordinated and integrated management, based on the patient-centred triangle consisting of healthcare providers - social workers – family. to educate patients and caregivers extensively with the intension of lowering deterioration and exacerbations of the underlying chronic disease. Aim and theory of change: The aim of the study is to improve the management of elderly patients, to decrease the incidence of exacerbations (especially those requiring hospitalisation), to hamper the deterioration of general health condition, and finally to reduce the cost of care. Target population and stakeholders: In the pilot study, the model of care would be delivered to 90 multimorbid elderly, recruited from three different healthcare pathways (primary care, n=30; patients with chronic heart failure, n=30; patients with chronic obstructive pulmonary disease, n=30). In our model, existing healthcare services will be broadened by: 1- Periodic evaluation by geriatricians with use of comprehensive geriatric assessment tools. 2- Regular home visits of specially trained carers, which include monitoring of general condition, encouraging appropriate physical activity and supporting adherence to medical recommendations, alerting about significant symptoms. 3- Comprehensive rehabilitation based on regular physiotherapy. 4- Using selected, simple e-health interventions. Timeline: 24 months. Highlights (innovation, Impact and outcomes): The primary outcome of the project is to design and testing of a model of home-based integrated care, which is innovative in Poland and CEC. The expected results include improvement in functional and cognitive status and quality of life of patients, followed by decrease in general demand for medical services, especially in-hospital, and selected health economics indicators. The secondary outcome is to increase the knowledge and competencies of social workers, nurses, physiotherapists and family members on the management of elderly chronically ill patients, and to improve cooperation between these groups and medical staff. Comments on sustainability: After the pilot study, the implementation of the model, or further testing on larger population, would be a matter of discussion between team members and decision-makers on local and national level. Comments on transferability: The proposed model of care seems to be possible to implement in Polish healthcare system, as it enhances coordination between already existing institutions and local care-providing structures. Conclusions (comprising key findings): Current work on designing the model indicates, that crucial area for change is to coordinate already existing institutional structures. Discussions: Detailed conclusions would be drawn after the testing the model. Lessons learned: The work on designing the model has already resulted in the successful creation of an active network of specialists from different backgrounds and allowed sharing different scopes, how to use limited resources for the benefit of the elderly.

Keywords

• integrated care. elderly. home-based care. pre-frail. rehabilitation