Ten years of integrated care for the older in France

Integrated Care for Older People in France in 2020: Findings, Challenges, and Prospects

BACKGROUND

We analyze here major changes over the last decade in the French healthcare system for older people, in terms of the integrated care concept.

POLICIES

During this period, the major theme of public policies was "care coordination." Despite some improvements, the multiplication of experimental programs and the multiplicity of stakeholders distanced the French healthcare system from an integrated care model. Professionals and organizations generally welcomed these numerous programs. However, most often, the programs were insufficiently implemented or articulated, notably at a clinical level, because of the persistence of a high level of fragmentation of governance, despite the creation of regional health agencies 10 years ago. The COVID-19 crisis has highlighted this fragmentation. Moreover, we still lack data on the impact of these programs on people's health trajectories and personal experiences.

CONCLUSION

The French healthcare system seems more fragmented in 2020 than in 2010, despite improvements in the culture of professional collaboration. The future health reform is an opportunity to capitalize upon this progress and to implement "integrated care." This implies a strong and continuous national leadership in governance and change management.

A Community Resource Navigator Model: Utilizing Student Volunteers to Integrate Health and Social Care in a Community Health Center Setting

INTRODUCTION

While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. In this case study, we describe the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations (CBOs). We then detail initial implementation outcomes and practical considerations for future work.

METHODS

We used the Ten Essential Public Health Services Framework to guide program planning of a student "Help Desk" model for a community health center. Planning included a literature review, observation of exemplar programs, development of a CBO directory, and evaluation of the center's patient population, clinical workflows, and data infrastructure. We piloted the model for two months. After pilot completion, we reviewed patient data to understand the feasibility of the student "Help Desk" model. We utilized planning and pilot execution materials, as well as pilot data, to develop and discuss practical considerations.

RESULTS

Design and implementation complemented ongoing social needs screening and referral to CBOs by center case managers. Patients were asked if they would accept telephone follow-up by volunteers two and four weeks after the clinic visit. Of 61 patients screened, 29 patients were referred for follow-up. Ninety percent were reached at least once during the follow-up period, and 48% of patients referred reported connecting to at least one CBO. Only 27% of patients required escalation back to case managers, and no emergency escalation was needed for any patients. Students, faculty advisors, and community health center frontline staff and leadership supported the scale up and continuation of the "Help Desk" model at the community health center.

DISCUSSION

Successful implementation required multi-sectoral collaboration, well-defined scope of practice, and data interoperability. Student volunteers are untapped resources to support integrated health and social care.

Integration of health services for the elderly in Asia: A scoping review of Hong Kong, Singapore, Malaysia, Indonesia

Against the backdrop of rapid ageing populations, there is an increasing recognition of the need to integrate various health services for the elderly, not only to provide more coordinated care, but also to contain the rapid cost inflation driven primarily by the curative sector. Funded by the Asia-Pacific Observatory on Health Systems and Policies, this scoping review seeks to synthesize the received knowledge on care integration for the elderly in four Asian societies representing varying socioeconomic and health-system characteristics: Singapore, Hong Kong, Malaysia, and Indonesia. The search for English-language literature published between 2009 and 2019 yielded 67 publications in the final sample. The review finds that both research and practice regarding health service integration are at a preliminary stage of development. It notes a marked trend in seeking to integrate long-term elderly care with curative and preventive care, especially in community settings. Many distinctive models proliferated. Integration is demonstrated not only horizontally but also vertically, transcending public-private boundaries. The central role of primary care is highly prominent in almost all the integration models. However, these models are associated with a variety of drawbacks in relation to capacity, perception, and operation that necessitate further scholarly and policy scrutiny, indicating the robustness and persistence of siloed healthcare practices.

[Clinical characteristics, care professionals' intervention and care complexity for elderly patients in home hospitalization]

INTRODUCTION

The number of elderly patients in home care in France is currently increasing. Our objective is to describe the clinical characteristics, the care professionals' intervention and the complexity of follow-up care for this elderly population.

METHODS

This is a cross-sectional study with a sample of 50 elderly patients aged 75 and over living at home and followed-up in home hospitalization in 2016 by the Assistance Publique Hôpitaux de Paris. The collection of data used the interRAI-CA tool (Resident Assessment Instrument - Contact Assessment).

RESULTS

The average age of the sample was 84 years with 48% women, 26% living alone and 96% having a caregiver who had difficulty in caring in 33.3% of cases. Patients had numerous diseases with 68% of the sample who had cognitive difficulties with functional disabilities; Most of them reported pain and 52% had unstable clinical situation. The main care interventions were complex wounds, supportive care and palliative care with technical care and 80% of the sample mobilized more than 3 professionals. Care was considered to be of a high level of complexity for 74% of the elderly patients.

CONCLUSION

Our study showed that elderly patients had care complexity with technical and multi-faceted care implying coordination of stakeholders and support for caregivers. Implementing at-home hospitalization allows to transfer some geriatric patients from hospitalization to the home care and helps the structuration of the geriatric expertise among the primary care services.

<p>An Evidence-Informed and Key Informants-Appraised Conceptual Framework for an Integrated Elderly Health Care Governance in Iran (IEHCG-IR)</p>

Purpose

Population ageing has been steadily rising in Iran and in the over 60-year-old population, the ratio increased from 5.4% in 1986 to 8.6% in 2016 which represents an increase of 4.3 million over the past three decades. The inevitable impacts of a growing elderly population on the demand-side of the health care provision (HCP) equilibrium call for an urgent revision of the current arrangements of the Iran’s National health care system (INHS). The main aim of this study was to scrutinize the best available scientific evidence on the international integrated elderly health care governance (HCG) models to revamp health care practice and policy-making processes in Iran.

Materials and Methods

This multiphasic study consists of a scoping review of existent HCP modalities for the elderly population worldwide, and the disposition of an optimal HCP scheme for the elderly population and its application for the detection of the gaps in Iran. The final stage includes a Delphi-based consultation and consensus process which was reciprocated in three rounds and the key subjects were requested to give their judgment on the eventuated HCP layout designed to serve the ageing Iranian population.

Results

The yielded model (IEHCG-IR) included four dimensions consistent with the four levels of prevention along with social support services. The structure and feasibility of the preliminary framework were approved by 83.6% of the study participants.

Conclusion

The study findings could have important implications for future policy making in the INHS and the suggested healthcare framework for the elderly Iranian population could be a preliminary model for health system re-engineering.

Hospital Discharge Decisions Concerning Older Patients: Understanding the Underlying Process

ABSTRACTWe aimed to understand clinical decision-making processes that influence the orientation of older patients after hospital discharge. We compared discharge decisions (i.e., discharge home, or nursing home stay) of the hospital team with those of an expert panel. Both panel and hospital team made their decisions independently. The blind study included 102 patients (mean age: 83.13 ± 6.74). There is a statistically significant difference between expert and hospital team decisions (p &lt; .001; kappa coefficient: 0.468). Panel decisions were more closely associated with isolation (p = .018), reliable caregivers (p = .004), social problems (p = .001), and behavioural symptoms perceived as aggressive (p = .001). Both decision processes considered refusal of care (p = 0,025 and 0.016 respectively) and social problems (p = .001 and &lt; 0.001 respectively). Discharge planning models differ depending on the country, team and patient's condition. Our study suggests more precise evaluation of patients' needs.

Implementation of a Standardized Comprehensive Assessment Tool in France: A Case Using the InterRAI Instruments

BACKGROUND

The improvement of quality of care requires a standardized and comprehensive assessment tool but implementation is challenging.

PURPOSE

We have reported on the development of the interRAI instruments in France from the onset to the mandatory use at the national level. We also have identified in the literature and in practices, incentives and barriers for the implementation of this integrated clinical information system in long term care.

RESULTS

Three periods in the interRAI instruments development were identified over the last twenty years. The first one was a research approach about improving quality of long term care. The second one was an experimental clinical use into an integrated care model with case management. The third one was a call for tenders issued by a French national agency, and the choice to use the interRAI-HC (Home Care) for all case managers. The main incentives and barriers that were identified include the national context, the target population, the providers involved and the impact on their practice, the interRAI instrument characteristics, training and leadership.

CONCLUSION

This historical overview of the development of interRAI instruments in France gives health care organizations pertinent information to guide the implementation of a standardized and comprehensive assessment tool.

The development of integration in the elderly care sector: a qualitative analysis of national policies and local initiatives in France and Sweden

Due to a significant increase in the complexity of the care demands of older people having multiple care needs, the necessity for integrated care is increasingly acknowledged. Proposing a qualitative approach based on a secondary literature analysis and an empirical survey, this paper explores the integration policy of health and social care for older people having complex needs in two European countries – France and Sweden – where various policy measures aiming at developing and delivering integrated care can be identified: at the national level, through the supportive measures of organisational, institutional and/or professional integration from central government, and at the local level, with the implementation of concrete integrative initiatives. Using a comparative qualitative approach, the authors investigate both of these levels, as well as the interplay between them. They show the importance of this double – local and national – approach of the issue of integration and highlight the continuous negotiation process which underlies the integration activities. Local integration initiatives are in fact constantly reshaped by top-down and bottom-up dynamics which appear to be strongly interconnected.

Do Austrian "INTEGRI (integrated care) projects" comply with international definitions and concepts?

One of the biggest challenges for European healthcare systems is the fragmentation of care. To overcome this challenge, integrated care (IC) approaches have been recently implemented. To further improve this method, current and past projects must be monitored and evaluated. However, since the definition of IC is very indistinct and varies significantly in literature, key elements have to be defined. The study design selected was a mixed-methods study that includes two approaches: a systematic literature review and qualitative content analysis of the data provided by the Ludwig Boltzmann Institute. Nine key elements of IC projects were identified in the literature review and subsequently compared with the main features coded from previous INTEGRI applications. The results showed that 41 of the applications presented seven or more criteria in their official submission form. The conclusion of the results can be drawn as a justification and validation of the INTEGRI criteria. Although the results are positive on the whole, three recommendations on possible improvements are given.

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s

BACKGROUND

Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays.

METHODS

The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance.

RESULTS

During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions.

CONCLUSION

Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

[Use of social and health primary care services for older people with complex needs: Comparison of three types of gerontological coordination]

BACKGROUND

Older people with complex needs live mainly at home. Several types of gerontological coordinations have been established on the French territory to meet their needs and to implement social and primary health care services. But we do not have any information on the use of these services at home as a function of the coordination method used.

METHODS

We compared the use of home care services for older people with complex needs in three types of coordination with 12 months' follow-up. The three coordinations regrouped a gerontological network with case management (n=105 persons), a nursing home service (SSIAD) with a nurse coordination (n=206 persons) and an informal coordination with a non-professional caregiver (n=117 persons).

RESULTS

At t0, the older people addressed to the gerontological network had less access to the services offered at home; those followed by the SSIAD had the highest number of services and of weekly interventions. Hours of weekly services were two-fold higher in those with the informal coordination. At t12, there was an improvement in access to services for the network group with case management and an overall increase in the use of professional services at home with no significant difference between the three groups.

CONCLUSION

The use of social and primary health care services showed differences between the three gerontological coordinations. The one-year evolution in the use of home services was comparable between the groups without an explosion in the number of services in the network group with case management.

Methodological development of the interactive INTERLINKS Framework for Long-term Care

There is increasing international research into health and social care services for older people in need of long-term care (LTC), but problems remain with respect to acquiring robust comparative information to enable judgements to be made regarding the most beneficial and cost-effective approaches. The project ‘INTERLINKS’ (‘Health systems and LTC for older people in Europe’) funded by the EU 7th Framework programme was developed to address the challenges associated with the accumulation and comparison of evidence in LTC across Europe. It developed a concept and method to describe and analyse LTC and its links with the health and social care system through the accumulation of policy and practice examples on an interactive web-based framework for LTC. This paper provides a critical overview of the theoretical and methodological approaches used to develop and implement the INTERLINKS Framework for LTC, with the aim of providing some guidance to researchers in this area. INTERLINKS has made a significant contribution to knowledge but robust evidence and comparability across European countries remain problematic due to the current and growing complexity and diversity of integrated LTC implementation.

Multidisciplinary teams of case managers in the implementation of an innovative integrated services delivery for the elderly in France

BACKGROUND

The case management process is now well defined, and teams of case managers have been implemented in integrated services delivery. However, little is known about the role played by the team of case managers and the value in having multidisciplinary case management teams. The objectives were to develop a fuller understanding of the role played by the case manager team and identify the value of inter-professional collaboration in multidisciplinary teams during the implementation of an innovative integrated service in France.

METHODS

We conducted a qualitative study with focus groups comprising 14 multidisciplinary teams for a total of 59 case managers, six months after their recruitment to the MAIA program (Maison Autonomie Integration Alzheimer).

RESULTS

Most of the case managers saw themselves as being part of a team of case managers (91.5%). Case management teams help case managers develop a comprehensive understanding of the integration concept, meet the complex needs of elderly people and change their professional practices. Multidisciplinary case management teams add value by helping case managers move from theory to practice, by encouraging them develop a comprehensive clinical vision, and by initiating the interdisciplinary approach.

CONCLUSIONS

The multidisciplinary team of case managers is central to the implementation of case management and helps case managers develop their new role and a core inter-professional competency.

Adapting the Quebecois method for assessing implementation to the French National Alzheimer Plan 2008-2012: lessons for gerontological services integration

INTRODUCTION

Many countries face ageing-related demographic and epidemiological challenges, notably neurodegenerative disorders, due to the multiple care services they require, thereby pleading for a more integrated system of care. The integrated Quebecois method issued from the Programme of Research to Integrate Services for the Maintenance of Autonomy inspired a French pilot experiment and the National Alzheimer Plan 2008-2012. Programme of Research to Integrate Services for the Maintenance of Autonomy method implementation was rated with an evaluation grid adapted to assess its successive degrees of completion.

DISCUSSION

The approaching end of the president's term led to the method's institutionalization (2011-2012), before the implementation study ended. When the government changed, the study was interrupted. The results extracted from that 'lost' study (presented herein) have, nonetheless, 'found' some key lessons.

KEY LESSONS/CONCLUSION

It was possible to implement a Quebecois integrated-care method in France. We describe the lessons and pitfalls encountered in adapting this evaluation tool. This process is necessarily multidisciplinary and requires a test phase. A simple tool for quantitative assessment of integration was obtained. The first assessment of the tool was unsatisfactory but requires further studies. In the meantime, we recommend using mixed methodologies to assess the services integration level.

The French Society of Geriatrics and Gerontology position paper on the concept of integration

INTRODUCTION

The concept of integration, although dating from the 1990s, has only recently appeared in French public health policy. It must be linked with 'coordination', which is the base of most French public policies applied to geriatrics since the 1960s. Herein, we report the French Society of Geriatrics and Gerontology working group's findings according to three axes: definition of integration, objectives of this organisational approach and the means needed to achieve them.

DISCUSSION

Integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, financing, interventions and action-reports on the latter. Integration must be accompanied by a local dedicated professional (the 'pilot'). Results of recent experiments showed that it is possible to implement integrative dynamics in France.

Implementation and effectiveness of 'care navigation', coordinated management for people with complex chronic illness: rationale and methods of a randomised controlled trial

Background

Chronic illness is a significant driver of the global burden of disease and associated health care costs. People living with severe chronic illness are heavy users of acute hospital services; better coordination of their care could potentially improve health outcomes while reducing hospital use. The Care Navigation trial will evaluate an in-hospital coordinated care intervention on health service use and quality of life in chronically ill patients.

Methods/Design

A randomised controlled trial in 500 chronically ill patients presenting to the emergency department of a hospital in Western Sydney, Australia. Participants have three or more hospital admissions within a previous 12 month period and either aged ≥70 years; or aged ≥45 years and of Aboriginal or Torres Strait Islander descent; or aged ≥ 16 with a diagnosis of a respiratory or cardiology related illness. Patients are randomised to either the coordinated care program (Care Navigation), or to usual care. The Care Navigation program consists of dedicated nurses who conduct patient risk assessments, oversee patient nursing while in hospital, and guide development of a care plan for the management of chronic illness after being discharged from hospital. These nurses also book community appointments and liaise with general practitioners. The main outcome variables are the number of emergency department re-presentations and hospital readmissions, and quality of life during a 24 month follow-up. Secondary outcomes are length of hospital stay, mortality, time to first hospital re-admission, time to first emergency department re-presentation, patient satisfaction, adherence to prescribed medications, amount and type of in-hospital referrals made for consultations and diagnostic testing, and the number and type of community health referrals. A process evaluation and economic analysis will be conducted alongside the randomised trial.

Discussion

A trial of in-hospital care coordination may support recent evidence that engaging primary health services in care plans linked to multidisciplinary team support improves patient outcomes and reduces costs to the health system. This will inform local, national and international health policy.

Trial registration

Australia New Zealand Clinical Trials Registry ACTRN12609000554268

Successfully integrating aged care services: a review of the evidence and tools emerging from a long-term care program

Background

Providing efficient and effective aged care services is one of the greatest public policy concerns currently facing governments. Increasing the integration of care services has the potential to provide many benefits including increased access, promoting greater efficiency, and improving care outcomes. There is little research, however, investigating how integrated aged care can be successfully achieved. The PRISMA (Program of Research to Integrate Services for the Maintenance of Autonomy) project, from Quebec, Canada, is one of the most systematic and sustained bodies of research investigating the translation and outcomes of an integrated care policy into practice. The PRISMA research program has run since 1988, yet there has been no independent systematic review of this work to draw out the lessons learnt.

Methods

Narrative review of all literature emanating from the PRISMA project between 1988 and 2012. Researchers accessed an online list of all published papers from the program website. The reference lists of papers were hand searched to identify additional literature. Finally, Medline, Pubmed, EMBASE and Google Scholar indexing databases were searched using key terms and author names. Results were extracted into specially designed spread sheets for analysis.

Results

Forty-five journal articles and two books authored or co-authored by the PRISMA team were identified. Research was primarily concerned with: the design, development and validation of screening and assessment tools; and results generated from their application. Both quasi-experimental and cross sectional analytic designs were used extensively. Contextually appropriate expert opinion was obtained using variations on the Delphi Method. Literature analysis revealed the structures, processes and outcomes which underpinned the implementation. PRISMA provides evidence that integrating care for older persons is beneficial to individuals through reducing incidence of functional decline and handicap levels, and improving feelings of empowerment and satisfaction with care provided. The research also demonstrated benefits to the health system, including a more appropriate use of emergency rooms, and decreased consultations with medical specialists.

Discussion

Reviewing the body of research reveals the importance of both designing programs with an eye to local context, and building in flexibility allowing the program to be adapted to changing circumstances. Creating partnerships between policy designers, project implementers, and academic teams is an important element in achieving these goals. Partnerships are also valuable for achieving effective monitoring and evaluation, and support to ‘evidence-based’ policy-making processes. Despite a shared electronic health record being a key component of the service model, there was an under-investigation of the impact this technology on facilitating and enabling integration and the outcomes achieved.

Conclusions

PRISMA provides evidence of the benefits that can arise from integrating care for older persons, particularly in terms of increased feelings of personal empowerment, and improved client satisfaction with the care provided. Taken alongside other integrated care experiments, PRISMA provides further evidentiary support to policy-makers pursuing integrated care programs. The scale and scope of the research body highlights the long-term and complex nature of program evaluations, but underscores the benefits of evaluation, review and subsequent adaptation of programs. The role of information technology in supporting integration of services is likely to substantially expand in the future and the potential this technology offers should be investigated and harnessed.

Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation

INTRODUCTION

In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner's Chronic Care Model.

METHODS

Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation.

RESULTS

Most staff thought that care for their patients had improved. More patients reported having a care plan but they found it significantly harder to see a doctor or nurse of their choice and felt less involved in decisions about their care. Case management interventions were associated with a 9% increase in emergency admissions. We found some evidence of imbalance between cases and controls which could have biased this estimate, but simulations of the possible effect of unobserved confounders showed that it was very unlikely that the sites achieved their goal of reducing emergency admissions. However, we found significant reductions of 21% and 22% in elective admissions and outpatient attendance in the six months following an intervention, and overall inpatient and outpatient costs were significantly reduced by 9% during this period. Area level analyses of whole practice populations suggested that overall outpatient attendances were significantly reduced by 5% two years after the start of the case management schemes.

CONCLUSION

Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs. However, to improve patient experience, case management approaches need to be introduced in a way which respects patients' wishes, for example the ability to see a familiar doctor or nurse.