Primary Care and Care for the Older Persons

I. Introduction II. Primary CareIII. Profiles of aging, health of older populations and of older personsIV. Patterns of aging and the individual experience

a. Morbidity and multimorbidityb. The development of frailty and dependencec. Social isolationd. Patient perspectives : what do older persons want themselves

V. Informal careVI. What primary care has to offer to the older patients

a. Assessment b. Maintenance of good health and health promotion c. Advocated. Palliative care

VII. Organisation of primary care, lessons learneda. Patient centred co-ordination b. Coordination and integration of care : a complex task, who has to do it? c. Coordination and integration of hospital care and primary care

VIII. Specific Issuesa. Falls and their prevention b. Abusec. Palliative d. Polypharmacy e. Self care

IX. Obstacles to providing primary care for the elderly X. What policies do European countries have to strengthen or support primary

care for older personsXI. Needs for research and further developments

a. Pharmaceutical careb. How to successfully implement new models of older person’s care in

primary carec. Develop research on multimorbidity in primary cared. Develop transitional programs and research

Contributing Authors

Boeckxstaens PaulineIsabelle VedelUlrike Junius WalkerMartina HasselerCarmen de la CuestaJean-Pierre BaeyensJan De LepeleireHanna KaduskiewiczPim De Graaf

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I Introduction

The year 2012 will be the European year of healthy aging. This Position Paper addresses the response by primary care to the health needs of increasing numbers of old persons in European countries. Refreshing ideas and experiences are emerging in different countries in Europe on how to offer adequate primary care and on how to organise that – and ho to contribute to healthy aging as well.

While convergence takes place of role and functions of Primary Care, the organisation, structure and funding base varies widely between countries. Also, some countries have developed a strong and coherent Primary Care system whereas others are less oriented towards the community and more to hospitals. No country however can claim to have a Primary Care system that is sufficiently robust to adequately address all the challenges it meets – including the adequate provision of care for the older persons. Primary Care reform is ongoing in many countries. It is the diversity and reform of Primary Care that makes international studies and comparison rewarding.

Intended as an inspiration to policy makers, practitioners and researchers across Europe, in this Position Paper we examine the demands on Primary Care with regards to the needs of older people, its responses across Europe and the challenges further ahead1. Good policies and practices as well as innovations are highlighted and an agenda for research is discussed. This Position Paper does not claim encyclopaedic completeness, it rather aims to show variety. Because of the diversity between countries, organizational examples would often provide little understanding about the critical factors for success or failure in a specific setting. The differing contexts in which people work require that solutions be tailored to national circumstances. Therefore, we aim at discussing generic issues for Primary Care rather than describing how services are being organized.

This Position Paper has been developed in 2010 through a Medline search on the terms Primary Health Care and health services for the aged for the years 2004 - April 2010 and through an expert consultation process which has been designed by the European Forum for Primary Care2. It is one of a series of Position Papers that is being published since 2006.

II Primary CareIn this paper, we make no distinction between Primary Care and Primary Health Care (PHC). PHC is not a fixed organisational structure or level of care, that can be easily and unambiguously identified. Instead, it is considered as a combination of essential characteristics that are promoted by the PHC movement since more than 30 years:

Care that is easily accessible – in the community, without financial or physical (distance) barriers.

Person oriented care and not disease or organ oriented care. This implies attention for functioning and autonomy of people and requires continuity of care.

Comprehensive and quality care, implying evidence based generalist care for all common health problems. It includes collaboration with specialist services where generalist services are insufficient.

1 Reference to a number of country policies, like UK, Netherlands, France, Slovenia etc2 See www.euprimarycare.org

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Responsibility for the health of people in their community, which implies attention for determinants of ill-health and social aspects.

People are partners in managing their own health.

PHC did not emerge spontaneously and it requires a constant effort and well planned design to ensure PHC that is performing. According to the World Health Report of 20083 most countries would benefit from four major reforms:

1. Universal coverage reforms, to improve health equity; 2. Service delivery reforms, to make health systems people-centred and of high medical

quality.3. Leadership reforms, to ensure the development of coherent health systems;4. Public policy reforms, to promote the collaboration between public health and primary

care, addressing the health of communities as well as individuals.

III Profiles of aging, health of older populations and of older persons.

For Europe the proportion of people aged 65 years and older is projected to grow from just under 15% (in 2000) to 23.5% by 2030, while the proportion of those aged 80 years and over is expected to more than double (from 3% in 2000 to 6.4% in 2030)1 However, the pace of aging in Europe differs considerably between countries. Turkey and Ireland have the lowest proportion of people over 65 years of age (respectively 6 and 11 %), Germany and Italy have the highest proportion (approximately 20 %) 4. In all countries these percentages are higher for females than for males and they are increasing. As a result of increasing longevity, currently, at the age of 65, females have a life expectancy of 15 (Turkey) to 22 (Spain) years. For males these figures are respectively 13 (Slovak Republic and Hungary) and 18 (Switzerland) years2.

According to some345, the increase in longevity results in compression of morbidity, meaning that, as populations adopt healthier lifestyles and therapeutic advances continue, the period of illness that individuals experience before death is getting shorter. Others6 observe and expect a shift of morbidity to higher age groups, without clear compression: morbidity starts later and lasts as long as it did in previous decades. Further, in some population groups, unhealthy life styles, genetic and context factors lead to an early start of chronic disease like COPD and diabetes leading to a very long period with chronic illness. Next to morbidity, frailty leading to disability, comes into play: very frail people aged 80 years and over are major users of informal care and health and social services7,8. Finally, in some population groups life expectancy is considerable lower than in general, like in the migrant and Roma population in many European countries. All four phenomena occur in different population sub-groups, that have only partially been identified: in the lower socio-economic strata life expectancy is shorter and receptiveness for life style recommendations is lower than in higher socio-economic groups. On average, older persons without a partner have worse physical and psychological health than persons with a partner. How the general – but not uniform – increase in longevity will play out in volume of demand on primary care is unclear as yet.

Older people are as much a heterogeneous group as persons from any other age group. Primary care needs to shape itself in such a manner that it is possible to give an individualized response to older persons, taking into account their specific needs and wishes. Recognising

3 Primary Care: now more than ever. WHO 20084 http://stats.oecd.org; data on 2008

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patterns of disease and of needs helps to shape service delivery systems and the resources required. Therefore, the next chapter reviews the needs of older persons.

IV Patterns of aging and the individual experience.

We distinguish three distinct but interacting problem areas in older persons:

1) Morbidity and multimorbidity.

Many previously chronic diseases can now be treated with quick and good results: impaired vision because of cataract is treated with the lens-implant, hip and knee replacements restore mobility, angina pectoris can be treated with stenting. These interventions are not yet available to all populations in Europe, however. In contrast to these achievements, the prevalence of chronic diseases such as depression, dementia, Parkinson’s disease, cardiovascular disease, COPD and stroke is rising. Some diseases are more or less typical for older people such as dementia (...% of all cases above age ...) and other diseases are much more prevalent in the older population: malignancies (6/7 above age 50 and 3/7 above age 70), Parkinson’s disease (...% of cases above age ...). Some diseases may start earlier but their prevalence rises sharply with age (diabetes, COPD).

Together with the rising prevalence of chronic diseases, the prevalence of multimorbidity is rising. In patients over 65 it varies between 50% and 80% with higher prevalences reported within general practices compared to population surveys (Fortin, Hoffman, Daveluy). For people over 80 prevalences of over 70% are reported (Van den Akker, Wolf, Fortin). According to some authors, patients with multimorbidity represent the rule rather than the exception within primary care (Van Weel and Schellevis, 2006, Fortin 2005). Multimorbidity is a complex phenomenon with an almost endless number of possible disease combinations with a large variety of implications. In general, multimorbidity is associated with poor quality of life, physical disability, high healthcare utilization, hospitalisation and high healthcare costs and mortality9. Moreover, patients with multimorbidity receive less preventive care, lower intensity of treatment for certain conditions, less attention to psychiatric comorbidity. However, older persons with multimorbidity do not necessarily rate their own quality of life as low10.

The development and use of clinical practice guidelines in primary care is a major achievement of evidence based medicine of the last 20 years in most countries in Europe. However, being disease specific in set up, they have some limitations when used in persons with multimorbidity11121314. For example recommending exercise to improve health of a person with diabetes or COPD may be complicated if osteoarthritis limits movements due to pain or if lack of motivation is caused by depression. Currently, many patients with multiple conditions face polypharmacia, fragmentation of care, competing or conflicting guidelines, and inattention to their own preferences and concerns1516.

In daily practice guidelines are questioned and modified based on the context of the patient. Comorbid diseases, patient preferences, functional status, quality of life, life expectancy and environmental factors will be of influence. It is clear that managing multimorbidity, is much more than simply the sum of separate guidelines (Van Weel and Schellevis 2006). There is a need to develop strategies for the inclusion of the clinical and practical aspects of multimorbidity in clinical practice guidelines. PHC needs it own and adapted tools to take important clinical decisions.

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2) The development of frailty and dependence.

There is much heterogeneity in the degree to which frailty affects older people. While some have many problems, others age successfully. The introduction, some years ago, of the concept of successful aging voiced a change in thinking about 'age-related' decline. It marked the awareness that functional loss and dependency cannot simply be seen as consequences of the aging process itself when disease is absent. With this understanding these 'age-related' deficits became amenable to intervention. Indeed, several definitions of frailty exist, but a useful definition in primary care covers the different determinants and their coherence; is predictive for risks – like falls – and for worsening of a person’s condition; helps to focus interventions. The Tilburg Frailty Index is a screening instrument being developed in the Netherlands, based on these criteria. It includes various components, ranging from hand grip strength to social relations.

Another definition17 describes a frailty phenotype in which weakness, tiredness, poor endurance, weight loss, low levels of activity and slow gait speed were defined as core elements. Three or more features indicate frailty and one or two features indicate pre-frailty. The SOF-index18 defines frailty by identifying the presence of two or more of the following three components at the second examination:

1. Weight loss;2. Inability to rise from a chair five times without using the arms;3. Poor energy as identified by an answer of “no” to the question “Do you feel full of

energy?” on the Geriatric Depression Scale.A person with none of the above components is considered as robust, and persons with one component are considered to be in an intermediate stage.

Some US studies show that frailty affects about 7% of people aged 65 years or older and about 25-40% of those aged 80 or older19. Santos-Eggiman20estimates frailty to affect about 17 % of patients older than 65 in ten European countries with higher proportions in southern than in northern Europe. She found a strong relationship between education and frailty and an attenuation of country effects after adjusting for this factor.

Frailty reduces older persons’ independence. Australian figures indicate that while only one in 20 of those aged 65-69 require assistance with self care activities, this rises to one in three among those aged 80 years and over21. In Serbia, among those aged over 80, 85,1% reports to need assistance from other persons in various activities of daily living22. Often, frailty leads to recurrent hospitalization 23 and institutionalization 24.

Frailty appears to be a dynamic and also potentially reversible process, early recognition of frailty and early interventions are of the essence and therefore an importance issue for Primary Care.

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3) Social isolation.

In surveys carried out among the general public loneliness and social isolation are often named as a very serious problem for older adults. Epidemiological data show that loneliness is especially a problem of the very old. Of those aged 80 and over, 40-50% report they are often lonely 25. Desperate need for contact might lead to physical complaints or exacerbation of physical complaints and provoke the use of health services. Loneliness and social isolation have been related to depression, higher blood pressure, worse sleep, immune stress responses and worse cognition over time26. In the UK, living alone in later life is seen as a potential health risk being independently associated with multiple falls, functional impairment, poor diet, smoking, the risk of social isolation and some reported chronic conditions27. Social networks including a spouse and larger networks of close relatives and friends mitigate the influence of depressive symptoms on some HRQOL scales. 28. In the central and northern European countries, family links are weaker whereas in the Mediterranean countries stronger family ties are more prevalent. These differences are reflected by higher levels of institutionalisation and solitary living in countries with an individualistic tradition. However, reported loneliness varies widely within countries and in general the southern European countries show a high prevalence of reported loneliness, while it is less common in western and northern Europe 29. Loneliness is often confused with social isolation. Loneliness is a negative, subjective experience, whereas social isolation is the objective condition of not having ties with others (which can be counted by the number of social contacts a person has, for example)3031. General practitioners and community nurses are in a unique position to identify loneliness as they are in contact with very old people, bereaved people and people with disabilities- the three groups most at risk. They are capable of discussing individually tailored initiatives with the patients to ease their distress of loneliness.

4) Patient perspectives : what do older persons want themselves?

The 3 categories of problems mentioned above occur in always changing combinations and intensity, which calls for individual assessments rather than for grouped approaches. Further, measurements of quality of life tell another story than the list of 3 problem areas may suggest: older persons do not rate the quality of life lower than young persons, see figure 1. Also, in dementia it has been shown that the reduction of QOL over time is far less explicit than supposed (Missotten et al., 2008)

Figure 1.

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Further, recent research shows that the experiences and perspectives of older people themselves may not be the same as the needs as identified by professionals. The following themes emerged from several studies32. Patients describe ideal care as patient centered and individualized with convenient access to providers (telephone, internet, in person), clear communication of individualized care plans, support from a single coordinator of care who can help patients prioritize the competing demands from their multiple conditions and continuity of relationships. Further, many patients express a great appreciation of services even if they have limited expectations of improvement in their health status that those services could bring about33. Patients especially value face to face, personalized and flexible appointments. Underutilization of services by older persons occurs regularly and is explained by three thresholds: (1) the services offered do not cater for their needs (2) their own frailties limit the access or use of the services and (3) lack of service flexibility. This latter point deserves emphasis: people want the timing and kind of care to be tailored and coordinated with their individual circumstances.

Optimal care means patient involvement and empowerment, including being informed about every stage in the care process. Patients’ influence in the decision making process is greatly appreciated3435. The home is generally perceived as the last area over which people are able to assert control and retaining that control is a priority for many older persons.

V. Informal care

Informal care is mostly delivered by relatives36. While providing informal care is a natural part of our relationships and social capital in society, currently, there are different views in European countries on the role that informal care should play. As mentioned above, in southern European countries, informal care is much more regarded as the natural and preferred model of providing care while in northern European countries older persons are entitled to home care that is provided by society. Both approaches however have their limits. Because relatives are unable to provide the informal care that is required, in some countries immigrant caregivers are increasingly being hired to care for older people. Budget constraints

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and unavailability of personnel in northern European countries limit the support to home care that the health and social care system can provide and the demand for informal care is on the rise. While combinations of informal care and formal care – community nursing, for example – occur frequently, collaboration between informal and formal carers may be problematic in the sense of (lack of) respect, trust and coordination37. Older people who are caregivers may also be isolated and lonely. About a third of carers report feeling lonely at least sometimes 38. Nevertheless, providing informal care often gives an important sense of meaning in the life of the caregiver. Primary care has a crucial position to monitor, detect and discuss the burden of care for caregivers and provide them the support necessary to optimize their role.

Box with two examples Spain: use of immigrants for informal careSerbia: quasi inexistence of nursing homes with heavy pressure on informal care

VI What Primary Care has to offer to the older patients.

Primary Care practitioners have the – unique - responsibility and potential to address the needs of older persons as felt by the older persons themselves. Unique, because they see the persons in their own environment, during a long period of time, with an understanding for the medical and non-medical life history of their patients and with the capacity to discuss the approach to their general and health. The practitioner has the possibility to assess how the combination of frailty and physical dependence with co-morbidity and social isolation – or the absence of these - work out in a particular patient. Organ or disease oriented specialists do not have that luxury: they see only a fraction of the reality of the patient – often in the short period of time a clinical consultation allows for. Despite the usefulness of disease management programs for individual chronic diseases, these interventions always have to be evaluated within and weighed against the context and needs of the patient.

In addition to being patient centred, strong primary care also reduces the need for hospital care because it can provide care that previously had to be provided in a hospital setting and because it can prevent worsening of conditions by early intervention39.

Below we describe several elements of the appropriate care that Primary Care should strive to deliver.

Assessment

In order to cope with the large numbers of elderly who need a person centred approach, methods and tools to assess needs are being developed. There is such an wide array of methods, that in the UK a series of criteria for accreditation of assessment tools has been developed, one of them being STEP: Standardised Assessment of Elderly People in Primary Care in Europe. The EASY-Care system is a set of Assessment Instruments, guidance and training in good practice for the assessment of the health and care needs of older people and adults with long term conditions.  Originally developed by the WHO (1990-1994) the EASY-Care system is particularly useful for obtaining a rounded assessment of need and personal response in at-risk older people and living in the community. The EASY-Care Assessment Instruments currently are available in 16 European languages and they are under continuous development based on a strong research programme, together with user feedback. There is strong evidence on the benefits of comprehensive geriatric assessment (CGA40) for older

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people. CGA utilises multidisciplinary specialist expertise and therefore requires a significant investment. Front-line professionals such as community nurses can identify those who need CGA.

Setting priorities with older patients in general practice, the case of Germany

General Practitioners (GPs) increasingly deal with the multiple health problems of older patients. The consultation is central to identifying and treating health problems. However, traditionally it does not lend itself to the complex needs of older patients. It is set up to react to patients’ single complaints focussing on separate disease managements. In Germany, general practice consultations are among the shortest in Europe (on average 7.6 minutes5), and older patients visit their primary care doctors on average between 30 and 40 times a year6. This time may be better spent.

A two-tier proactive approach is being developed that involves a comprehensive assessment to gain a health overview followed by a consultation, in which priorities are set. The STEP-assessment originates from a European concerted action and is tailored to the needs of older patients living at home7. It discloses on average about 13 health conditions and problems of everyday life per patient8. On the basis of the assessment results a consultation takes place to generate an individual care plan. The multiple health problems often necessitate a reduction of treatments to an essential minimum. This involves a process of setting priorities and includes the perspectives of the patient and the doctor.

Research has shown that patients and doctors do not intuitively agree on the importance of individual health problems9. GPs confirm that they often set priorities independently in consultations- rather than in communication with the patient10. Therefore priority setting requires a transparent communication process that is patient-centred and facilitates shared decision making.

Maintenance of good health and health promotion.

5 Van den Brink-Muinen A. Verhaak P, Bensing J, Bahrs O, Deveugele M, et al. The eurocommunication study. http://www.nivel.nl/pdf/eurocomm.pdf [ 31.10.2010]

6 Iseg, Institut für Sozialmedizin, Epidemiologie und Gesundheitssystemforschung. Barmer GEK Arztpreport. Auswertungen zu Daten bis 2008. Aasgard Verlag, St. Augustin 2010, p219

7 The Step-Panel: Williams I, Fischer G, Junius U, Sandholzer H, Jones D, Vass M, et al. An evidence-based approach to assessing older people in primary care. Occas Pap R Coll Gen Pract 2002;82:1-538 Piccoliori G, Abholz H. Geriatric Assessment in General Practice- A study of the South Tyrolean Academy of General Practice. ZAllg Med 2005;81;467-16 [in German]

9 Voigt I., Wrede J., Diederichs-Egidi H., Dierks ML., Junius-Walker U. Priority setting in general practice. Health priorities of older patients differ from treatment priorities of their doctors. accepted in CMJ 2010

10 Junius-Walker U, Voigt I, Wrede J, Hummers-Pradier E, Lazic D, Dierks ML. Health and treatment priorities in patients with multimorbidity: Report on a workshop from the European General Practice Network meeting ‘Research on multimorbidity in general practice’. Eur J Gen Pract 2010; 16: 51-4.

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A pessimistic approach to ageing and older patients might lead to impeding the promotion of health and active life in older age. Health promotion interventions in later life require a different focus than those at younger ages, with an emphasis on reducing age-associated morbidity and disability and the effects of multimorbidity. Even a small reduction of disability may translate into large health care savings and improvements in the physical, emotional and social health of older persons. According to the UK’s National Health Service, there is a growing body of evidence to suggest that the modification of risk factors for disease even late in life can have health benefits for the individual: longer life, increase of maintenance of functional abilities, disease prevention and an improved sense of well being. However, a narrative literature review41 on health promotion measures and interventions on long term care indicated a lack of findings on effective health promotion measurements and interventions for elderly.

b) Prevention of falls in primary care has gained wide interest because it has shown to be effective.

c) Morbidity and multimorbidity

Care for older patients with more than one chronic disease and need for complex care, (Boyd CM 2005) often get care that is incomplete, not coherent and insufficiently effective. They should get care that is modeled around the following processes42:

A regular and comprehensive assessment of their health. Coherent and evidence based care and monitoring of care. Stimulation of the competences and involvement of informal carers Coordination between care providers.

DISEASE MANAGEMENT PROGRAMS IN GERMANY: MULTIMORBIDITY NOT SUFFICIENTLY ADDRESSED.

In Germany, six disease management programs (DMPs) for chronic diseases were introduced since 2003 on a nationwide basis within the statutory health insurance, which covers 86% of the German population. These DMPs focus on breast cancer, type 1 diabetes, type 2 diabetes, asthma, chronic obstructive pulmonary disease and coronary heart disease. Participation in the DMP is voluntary for physicians and patients. Medical services in the DMP include treatment according to the best available evidence, a defined frequency of visits to the attending physician, rules for referral, regular examinations, physician counselling, documentation, and participation in education courses for doctors and patients.

There is no age limit for participation in the DMPs. However, the population-based approach is somewhat restricted as the law states that only those patients should be included who will participate actively in training and are expected to benefit from the program regarding quality of life and life expectancy. It is up to the attending physicians to decide if and how they apply these enrolment criteria. It is therefore conceivable that elderly and multimorbid patients are not enrolled in the DMP. On the other hand, GPs receive a lump sum for inscription of every single patient – which might promote enrolment. It is permitted and favoured that patients participate in more than one

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program if they suffer from the respective diseases. The handbooks that are used as medical guides through the programs for the GPs mainly focus on the single diseases. In the handbook for the DMP on cardiovascular disease (1) one chapter deals with “frequent comorbidity and complications”. This chapter is written by GPs and focuses mainly on pharmacotherapy in case of the following comorbid conditions: hypertension, arrhythmia, heart failure, depression, type 2 diabetes, asthma, COPD and peripheral vascular disease. In sum, multimorbidity is being addressed rather marginally in the German DMPs.

(1) Deutscher Hausärzteverband e.V., AOK-Bundesverband. Koronare Herzkrankheit (KHK). Hausarzt Handbuch. MED.KOMM. Verlag, München.

Advocate

Primary care practitioners are well placed to advocate for social and community support that complement informal and self care. Many older people use community services to help them remain independent. Frail older adults usually have multiple impairments and function best in environments they know. Since each move to a new setting may cause physical decline and depression we should guard it unacceptable that patients must give up their independence, to receive services they need, to remain as active as possible. (Rantz et al, ref 103)

BLACK BOX. QUALITY CARE FOR QUALITY AGING: EUROPEAN INDICATORS FOR HOME HEALTH CARE (Dario Zannon/ based on the document ).

Palliative carePalliative care and care at the end of life are essential elements of care for the older persons. The WHO extended the definition of palliative care (World Health Organisation, 2004).Little experience and knowledge exist on palliative issues in geriatric care. Some important issues are pain, dyspnea, behavioral disturbance, feeding and malnutrition. Dealing with existential and spiritual concerns is crucial.

Palliative care – in how far embedded in primary care – description of % of palliative care provided by GP’s and other primary care providers – in how far is this a specialised service. (input from UK and Slovenia is particularly interesting).

Quality of healthcare has to be monitored by the right indicators. Quality of health care for the older persons and patient safety are crucial (World Health Organisation, 2009; World Health Organisation, 2002b; World Health Organisation, 2002a; 2010). More attention should be paid to this issue.

VII Organisation of Primary Care, lessons learned.

Improving and reorganizing elderly care in modern health systems has become a priority in order to cope with the specific challenges of meeting the needs of older persons11

11 Mion L, Odegard PS, Resnick B, Segal-Galan F, Geriatrics Interdisciplinary Advisory Group AGS: Interdisciplinary care for older adults with complex needs: American Geriatrics Society position statement. J Am Geriatr Soc 2006, 54:849-852.Reuben DB: Organizational interventions to improve health outcomes of older persons. Med Care 2002, 40:416-428.

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Another challenge claim for the implementation of new models of care for older people rooted in primary care. Indeed, despite strong evidence of efficacy of integrated services in optimizing resource utilization and health and satisfaction levels among older persons in experimental context12, it has been difficult to diffuse and sustain these services, in large part because of difficulties encountered securing the participation of healthcare professionals and, in particular, primary care physicians (PCPs)13. These services have often been developed by specialist physicians. Moreover, there is a lack of an in-depth understanding of the context of primary care and of GP practices. Case managers were based on emergency department of home-based nursing services. This seems to explain the difficulties encountered in developing close relationship between case managers and GP. We can learn from these experiments that GPs should de integral part of the development process of integrated services. Moreover, integrated services should thus be based on GP practices (eg. Case managers should be co-located with GPs in family medicine group practices).

BLACK BOX : CASE MANAGEMENT ALZHEIMERIn Europe, some countries have a national dementia plan already: Norway (lauched in 2007), Netherlands (launched in 2008), France (2008), UK-England (2009), UK-Scotland (2010). Other plans are in preparation in Europe (Cyprus, Czech Republic, Belgium, Denmark, Malta, Portugal, Switzerland, UK-Wales) and in North America (Quebec). Even if these plans differ in substance, their global aims are to recognise Alzheimer’s disease and related disorders as a major public health challenge and to adress issues at the research, organizational and clinical level. For instance, the French Alzheimer’s Plan (http://www.plan-alzheimer.gouv.fr/) covers 44 important recommendations with an allocation of 1,6 billion euros over 5 years. This plan aims to integrate research, medical care and social care. Three priorities emerge.

- To improve our understanding of Alzheimer’s disease. One objective is to “produce an unprecedented effort for research”.

- To improve the quality of life for patients and their carers. The MAIA, integrated services for patients with Alzheimer diseases and their family are being implemented and evaluated. A single entry point is accessible for every patient. They have access to a dedicated case-manager who will design an integrated plan of health and social care suitable for the patient. Other actions are the development of respite care, carer training programmes, domiciliary care services as well as the setting up of a network of nursing homes.

- To change the way people look at Alzheimer’s disease and to set up a new status of the patient.

Morris J, Beaumont D, Oliver D: Decent health care for older people. BMJ 2006, 332:1166-1168.

12 Johri M, Beland F, Bergman H: International experiments in integrated care for the older persons: a synthesis of the evidence. Int J Geriatr Psychiatr 2003, 18:222-235.Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S: Complex interventions to improve physical function and maintain independent living in older persons people: a systematic review and meta-analysis. Lancet 2008, 371:725-735.

13 Reuben DB: Organizational interventions to improve health outcomes of older persons. Med Care 2002, 40:416-428.Beland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, Dallaire L: A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2006, 61:367-473.Johri M, Beland F, Bergman H: International experiments in integrated care for the older persons: a synthesis of the evidence. Int J Geriatr Psychiatr 2003, 18:222-235.Newcomer R, Harrington C, Kane R: Challenges and accomplishments of the second-generation social health maintenance organization. Gerontologist 2002, 42:843-852.

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The different plans developed in Europe and Quebec differ substantially. With regard to Primary care, the following questions remain: should the detection, the diagnosis, the communication of the diagnosis to patient and the initial treatment of dementia be the responsibility of primary care physicians or specialist physicians (eg. geriatricians, neurologist, and psychiatrists)? What should be the respective role of general practitioners and specialists physicians? In France and UK-England, the choice has been made to give the responsibility to specialists which is very debatable. In Quebec, GP are in the first line and specialist support GPs in the complex cases. Overall, it seems essential to integrate the GP in the detection, diagnosis and treatment process and to recognize their essential role in caring for patients with Alzheimer disease. Moreover the development of specific guidelines or services for a given chronic disease is challenging as far as older people with multiple chronic disease are concerned. The GP is the clinician who can integrate information from various specialists. He should thus be closely associated with treatment decisions and with the development of the care plan.

Patient centred co-ordination

Person centered care needs to be provided by services that are coordinated around the needs of the older person with respect to their individuality, dignity and privacy. To avoid service system failings that undermine older people’s confidence and their ability to remain independent, the services need to be integrated, aiming at promoting good health and quality of life and to prevent or delay frailty and disability. As mentioned above, this includes the introduction of a single assessment process in health and social care to ensure that older people’s needs are assessed and evaluated fully.

BLACK BOX. SINGLE POINT OF ACCESS - ITALY

Across Europe, a fundamental problem is the lack of common definitions of underlying concepts. Integration and coordination have been pursued in many ways in different health systems and there is a plethora of terminologies (“integrated care”. “coordinated care”, “collaborative care”, “managed care”, “disease management”, “person centred care”). This very much reflects the polymorphous nature of a concept that is applied from several disciplinary and professional perspectives and is associated with diverse objectives: caring for persons with multiple needs in the medical and social field; caring for people with chronic conditions; a health system perspective;). It is mandatory for every health system to evaluate and design its services and policies with the patient at the centre. Every attempt for coordination/integration that is not patient centered will lead to greater fragmentation.

Coordination and integration of care : a complex task, who has to do it?

Empiric and research evidence shows that the central medical professional for the care and management of multiple chronic diseases is the GP. This is related to his broad expertise but also to the usually longstanding relationship with older patients that ensures that the (medical) history of the person is taken into account43. Several studies demonstrated associations between physician-patient continuity and satisfaction, reduced utilization, increased efficiency and better preventive care4445. The task of coordinating care is both clinical and oriented towards the process of care. However, evidence abounds that GP’s are not well positioned to do the full co-ordination46. In several countries, case managers are being introduced:

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community nurses, social workers or other professionals who help the older patient/client to coordinate all the professionals.

A main issue is the increasing workload in which a range of formal and informal carers are involved47. While this is not specific for care for older persons, it does require more emphasis: primary care is multidisciplinary teamwork An issue for GP’s is that other staff in primary care – community nurses, pharmacists, social workers – may have their own relationship with the patient and have information from the patient. The unique relationship between patient and GP is not so unique anymore and the GP needs to relinquish control and become a team player4849. Obviously, this new role needs preparation, training and support. uitwerken

Recent developments in Information technology (IT) started to improve healthcare delivery and health outcomes at home and in primary care, particularly in geriatrics and in chronic disease care14. Numerous IT tools have been developed for care of older persons: electronic health records, decision support systems, telecare, web-based package for patients/ family caregivers, assistive technology etc15. Yet, despite the benefits of IT, numerous accounts show IT implementation failures and low adoption rates16.

Continuity of care. Living independent at home. Consequently, services like Community Alarms (CA’s) are highly regarded by older people. They are appreciated for raising confidence about being at home.” help is at hand at all times” (Themessl-Hiber).

Coordination and integration of hospital care and primary care.

Many older persons will need hospitalization for specific interventions or during exacerbations of chronic illness. Evidence shows that, the better the co-ordination between primary and secondary care, the shorter the average hospital stay is.

BLACK BOX. BELGIAN CARE PROGRAM FOR GERIATRIC PATIENTS A good example could be here the “Belgian Care program for Geriatric Patients”, where trough Geriatric Day Hospitals and an External Liaison in each hospital in Belgium a maximum of knowledge is transferred to the GP and his team and continuity is warranted.

In France, a model of integrated services – Coordination of Professional Care for the Elderly (COPA) – has been developed by a design process in which health professionals, including GPs, and managers participated actively (Vedel 2009 Implementation Science17). COPA targets older persons with functional and/or cognitive impairment who are identified by their GP. It is designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess of demand and supply of healthcare, including unnecessary emergency room (ER) visits and hospitalizations. COPA also

14 Weiner M, Callahan CM, Tierney WM, Overhage JM, Mamlin B, Dexter PR et al.: Using Information Technology to Improve the Health Care of Older Adults. Annals of Internal Medicine 139(5 II)()(pp 430-436), 2003 Date of Publication: 02 Sep 2003 2003, 430-436.15 Vedel I, Akhlaghpour S*, Lapointe L. Information Technology In Geriatrics: A Typology in support of IT diffusion. Canadian Journal of Geriatrics 2009, 12(1):4916 Casalino L, Gillies RR, Shortell SM, Schmittdiel JA, Bodenheimer T, Robinson JC et al.: External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA 289(4):434-41, 2003, -29.17 Vedel I, De Stampa M, Bergman H, Ankri J, Cassou B, Blanchard F, Lapointe L. Health care professionals and managers’ participation in developing an intervention: A pre-intervention study in the older persons care context. Implementation science 2009, 4:21

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prevents inappropriate long-term nursing home placements. The model’s originality lies in: 1) having reinforced the role played by the GP, which includes patient recruitment and care plan development; 2)  having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the GP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community who intervene upon a GP request. These geriatricians visit patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions50.

Further, geriatric expertise and dedicated care is developing in hospitals across Europe. However, not in all countries policy steers towards geriatric services in all relevant hospitals. In the UK, a recent evaluation of care for older persons says that a new range of acute and rehabilitation services is necessary to bridge the gap between acute hospital and primary and community care. The aim of those services should be to promote faster recovery from illnesses, promote timely discharge, maximize rehabilitation opportunities and independent living51.

VIII Specific issues (volgorde nog aanpassen)

(a) Falls and their preventionFor example, in falls, there needs to be :-a multi-sector strategy for increasing weight-bearing exercise in the general population of older people.

-a primary care response, including attention to vision, medicines, environment, exercise and bone health, to identify opportunities to reduce falls and fracture risk in the one in four people aged 65 plus who fall each year.

-referral to a multi-disciplinary falls and bone health service for those at greatest risk, such as those with a emergency hospital admission with a fall, a fall-related fragility fracture, or those with frequent falls.

(b) Abuse of the elderly

© Palliative care

(d) Polypharmacy52

Failure to adhere to medication among older people is a widespread and costly problem.Up to 50% of cardiovascular disease admissions may be due to poor adherence. In the Netherlands, more than 19.000 patients are hospitalized per year, as a result of potentially avoidable medication related problems.Older patients are subject to specific risk factors for non-adherence. Because they oftensuffer from more than one chronic condition and have a higher prevalence of diseases such as Alzheimer, Parkinson, glaucoma, osteoarthritis, and congestive heart failure they tend to take more medicines than their younger counterparts. The use of potentially inappropriate medicine (PIM) including prescribed medicines is a well known phenomenon.Moreover, older patients are more likely to face problems of memory and ofunderstanding regimens and instructions. Finally, problems with visual acuity (e.g.,

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reading the information leaflet or the mode of use on the label) and dexterity (e.g.,opening the vial of a bottle or pushing a pill out of a blister) may hinder their ability totake their medication properly.Furthermore, older patients are very sensitive to adverse effects of psychotropicmedicines, e.g. cardiac toxicity, confusion and unwanted sedation.10 The emergence ofside effects and the delayed onset of action of medicines lead to high rates of nonadherence to medication. Medication counselling and treatment monitoring conducted by pharmacists can improve medication adherence among people commencing therapy with psychotropic medicines.

Pharmacist-conducted medication reviews and subsequent counseling targeting older people reduce and prevent drug-related problems as well as enable to reduce the number of medicines taken as well as the number of daily doses. These reviews are helpful to encourage good prescribing practices as they allow to identify misuse or abuse of certain medicines, particularly sleeping pills and tranquilizers.In addition, community pharmacists in collaboration with other members of thehealthcare team are developing specific interventions for older patients living in thecommunity. This includes homecare programmes which facilitate care of patients in amore familiar and comfortable environment and tackling as well problems of poor

(e) Self careInternational developments in self directed care. (ref 1-alakeson et al uit search PB). The program allows beneficiaries to manage their own budgets and choose services that met their care needs. Such developments have been observed in England, Germany and the Netherlands as a way of increasing patient centred care. Self directed care should allow consumers to meet specific individual needs and preferences to remain independent and in their own homes. Early results are promising however ... Cave : most vulnerable groups (need for a counselling service),; cave ; transfering a greater proportion of risk for unexpected health care needs to individuals. Cave : non-evidence-based care. Cave : privatisering

Vita Lesauskaite et al. Challenges and opportunities of health care for the aging community in lithanua. Gerontology,2006:52:40-44Jones H et al. A Slovenian model of integrated care for older people can offer solutions for NHS services. Nursing times;105:49-50.

IX. Obstacles to providing primary care for the elderly. 2-3 pagesIk stel voor de tekst van dit hoofdstuk te integreren in eerdere hoofdstukken en het niet al seen apart hoofdstuk te houden

Funding often is an obstacle to ensure well coordinated and integrated care. Current healthcare systems are largely built on an acute episodic model of care which is ill equipped to meet the long term and fluctuating needs of older people with complex chronic health problems. The mismatch between the needs of the population for proactive, integrated and preventive care for chronic conditions and a healthcare system where the balance of resources is aimed at specialized episodic care for acute conditions might be one of the reasons of the current rise in hospital admissions (Scottisch Executive, 2005).

Many GPs are not ready to care for the growing population of elderly people living at

home.So says Professor Rudi Westendorp geriatrics (LUMC).He advocates a new role for GPs

in the elderly. "A GP who is more involved, more listens, thinks, anticipates and defends the

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wishes of the elderly. The GP as a personal physician. "To enable this, the political

choices. "The older population, the less value is the specialist care. More space should be

developed for generalists. "

Chapter on hospital oriented/primary care centred care.

Family medicine groups (FMG) have been implemented in Quebec through a national reform. They look like GP trust in UK. A FMG is a group of physicians (6 to 12) who take care of registered persons who enroll voluntarily. These GP work closely with nurses practitioners and use information technologies. The aim of this reform is to provide easier access to a family doctor, extend the hours of access to family physicians, improve the quality of general medical care, improve patient follow-up and service continuity and avoid unnecessary visits to emergency rooms. There are some limited financial incentives for family physicians[17]. This kind of organization is very well suited for the care of patients with multiple chronic diseases18. Impacts FMGs’ implementation19 are numerous: improved organization of primary care, improved collaboration and coordination between physicians and nurses, increased patients’ loyalty with regard to their healthcare professionals. GPs feel less isolated and less overwhelmed. Impacts are also positive for patients: an increased patient satisfaction, improved accessibility to primary care, better communication between patients and healthcare professionals, extended comprehensiveness. (I Vedel)

In France, a qualitative study from 2004 to 2006 systematically gathered data on the current practices, issues, and expectations of healthcare professionals and managers with regard to elderly care20. The results have identified many issues: 1/ Inadequate needs assessment process within primary careThe needs assessment process is not centered on common geriatric syndromes, but rather on acute medical problems. Needs assessment performed by various health care professionals (GPs, nurses, social workers, etc.) are not shared. 2/ Inadequate coordination of primary care servicesNo one is responsible for coordinating services. GPs often tried to play this role, but they did not have enough time and sufficient knowledge of existing services. Moreover, fee-for-service

18Pineault R, Levesque JF, Roberge D, Hamel M, Lamarche P, Haggerty J. Accessibility and continuity of care: A study of primary healthcare in Québec. Montreal: Agence de la santé et des services sociaux de Montréal, Institut national de santé publique, Centre de recherche de l’Hôpital Charles Lemoyne; 2009. [cited 2010 21 Sep]. Available from: http://www.inspq.qc.ca/pdf/publications/911_ServicesPremLigneANGLAIS.pdf.

19Beaulieu MD, Denis JL, D'Amour D, Goudreau J, Haggerty JL, Hudon E et al. L'implantation des Groupes de médecine de famille : le défi de la réorganisation de la pratique et de la collaboration interprofessionnelle. [Implementing family medicine groups: The challenge in the reorganization of practice and interprofessional collaboration.]. Université de Montréal; 2006. [cited 2010 21 Sep]. Available from: http://www.medfam.umontreal.ca/chaire_sadok_besrour/ressources/publications.html. [in French].

Ministère de la Santé et des Services sociaux du Québec-Direction de l’évaluation. Évaluation de l'implantation et des effets des premiers groupes de médecine de famille au Québec, Évaluation Santé et Services sociaux. [Evaluation of the establishment and of the effects of the first groups of family medicine doctors in Quebec, Health and Social Services Evaluation.]. 2008. [cited 2010 21 Sep]. Available from: http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2008/08-920-02.pdf. [in French].

20 Vedel I, De Stampa M, Bergman H, Ankri J, Cassou B, Blanchard F, Lapointe L. Health care professionals and managers’ participation in developing an intervention: A pre-intervention study in the older persons care context. Implementation science 2009, 4:21

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remuneration of GPs and some other healthcare professionals is seen as one of the barriers to coordination, since the time they spent coordinating tasks was not compensated.3/ Inadequate coordination of primary and secondary careInadequate coordination between primary and secondary care led to poor continuity of care. Hospital-based professionals have poor knowledge of community-based services. The pressure to transfer patients quickly leads to poor discharge planning. GPs and geriatricians work in silo. 4/ Perceived consequences for patients and familiesThe overall needs of older persons are not being recognized or met in a timely manner, leading to ‘crisis’ situations. Consequently, while GPs know that an emergency room visit is an adverse experience for older patients, they still use it inappropriately (e.g., falls, overextended families) because it was the only way for them to gain access to a geriatric assessment. Moreover, transitions between settings were performed with insufficient exchange of information between clinicians. Poor coordination of care was therefore generating a vicious circle of emergency room visits and hospitalizations. Finally, families were left too often with a significant burden.

X. What policies do European countries have to strengthen or support primary care for older persons? 2 -3 pages

Many countries in Europe have developed a policy for health and care for older persons, in which care in the community plays a major role. The recognition of primary care as the preferred option for care because it allows people to stay in their own environment as long as possible and it is less costly than intra-mural care, has been growing but is not yet Europe wide. In Sweden, municipalities are responsible for care for the elderly. From the ‘90s onwards, the family as an important care provider has been rediscovered and supported. Intermediate types of housing, between staying at home and special care homes, are being worked out. self care, Preventive health care, and outreach activities such as preventive home visits are being stimulated by state grants. The grants can also be used for improving service and care, such as rehabilitation, drug administration and follow up, nutrition and care for persons suffering from dementia. A government white paper on “elderly care with dignity” has encouraged the government to introduce new policies – dignity based – and measures in order to secure a “national guaranteed standard” of service and care for elderly people.

UK

Policy with emphasis on maintaining independence in the community

Policy with emphasis on care in the community

Policy with emphasis on instruments and resources for

Finland XXX XXUK XX XXXThe Netherlands

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FinlandIn how far do these policies address the obstacles mentioned above?What priorities for primary care do these policies mention?

In many cases structural or funding issues contribute to the lack of cohesion and integration in the service system. Often a range of programs funded by different levels of government have been created. This often results in confusion for providers, referrers and clients, poor integration between services with difficulty in assessing information and navigating the

1 Kinsella and Philips, 20052 Publicatie besteld door Pauline3 Fries 19834 Parker and Thorslund, 2007, 5 Freedman 20026 Rudi Westendorp, Rotterdam conference of nursing, 20107 Audit commission 2000, 8 Hellstrom and Hallberg 20019 Gijsen et al.10 Reference to be provided by Hasseler.11 Boyd CM 200512 Van Weel and Schellevis 200613 Marengoni et al14 Andersonn 201015 (Ritchie 2007,)16 Boyd CM 200517 Fried et al (2001)18 index (Ensrud KE, Ewing SK, Taylor BC, Fink HA, Cawthon PM, Stone KL, Hillier TA, Cauley JA, Hochberg MC, radondi N, tracy JK, Cummings SR ; Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Int Med 2008; 168(4); 382-389? Ensrud KE, Ewing SK, Cawthon PM, Fink HA, taylor BC, Cauley JA, Thuy-Tien Dam, Marshall LM, Orwoll ES, Cummings SR ; A comparison of frailty indexes for the prediction of falls, disability, fractures and mortality in older men. JAGS; 2009; 57(3); 492-498). This SOF-index19 (Fried 2001 uit ref 32 PB). 20 Santos-Eggiman et al (2009)21 (Australian Institute of Health and Welfare).22 (Sevo et al. Needs assessment of the oldest old citizens of Belgrade23 Fried, 2001),24 (Bandeen Roche 2006) and death (Fried, 2001, Bandeen roche 2006, Fugate Woods, 2005, Ensrud, 2007; Ensrud 2008; Cawthon 200725 Dykstra. Older adult loneliness : myths and realities. Eur J Ageing 2009;6:91-100. 26 Luanaigh et al. Loneliness and the health of older people. Int J geriatric Psychiatry 2008;23:1213-122127 Kharica et al. Health risk appraisal in older people 1 : are older people living alone an at-risk group? BJGP 2007;57:271-276. 28 Callegos-Carrillo et al. Social networks and health related quality of life : a population based study among older adults. Salud. Publica Mex 2009;51:6-1329 Dykstra. Older adult loneliness : myths and realities. Eur J Ageing 2009;6:91-100.30 Dykstra. Older adult loneliness : myths and realities. Eur J Ageing 2009;6:91-100.31 Forbes. Caring for older people : loneliness. BMJ 1996;313:352-35432 (Themessl-Hiber, Bayliss et al, Potter at al)33 (Themessl-Hiber).34 (Themessl-Hiber). 35 (Bayliss).36 references37 Haggstrom et al (ref 135) Nolan??38 Forbes. Caring for older people. Loneliness. BMJ 1996; 313: 352-439 reference

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system. However different levels of funding also have a positive side as it creates diversity of services and models of delivery and can enhance quality and availability for consumers as well as providing multiple funding sources for providers. The greatest challenge is to stretch limited resources through better integration, coordination and communication. (Anne Marie Fabri ref 77) Integration, coordination and communication – bevoorrechte rol voor primary care?

XI Needs for research and further developments 2 pages

On perception by older person themselves?Strengthening country policies?

Pharmaceutical careThe use of medications in the care for elderly is important for several reasons.a. It is a complex process (prescription, delivery, intake, adverse effects, patient safety). What is good for one problem, may be bad for another problem. E.g.cortocoids may be good for COPD but bad for diabetes. The relevant research on these topics is scarce. An important problem is that drugs are tested in clinical trials with people with a mean age of 55 years, while the real patients taking the medicines have a mean age of 80 years...So, in older persons all physicians are prescribing out of label..., which is a real ethical problem.b. Causing quite some iatrogenic problems c. And therefore generating an important cost A review of the literature showed that there are no good data or results of good research concerning the strategies to create a ‘seamless care’ concerning drug use in the elderly53 Only recently the issue gets more scientific interest but is by far not clear what procedures are most effective54 Medication review is an important multidisciplinary activity55 New methods have to be looked for in order to overcome these problems56

How to successfully implement new models of older person’s care in primary care?

40 reference41 conducted by M Hasseler42 Boult C. en GD Wieland, Comprehensive Primary Care for Older Patients with Multiple Chronic Conditions, Nobody Rushes You Through, JAMA, (3.11.2010, vol 304, pp 1936-1943).43 Barbara Starfield, ref 4 uit ref 114).44 (Meijer, ref 3 uit ref 114)45 (ref 6, en 7 uit 114).46 Volpintesta Edward ref 87) .

47 Carlisle et al (UK-1997),48 (modin, 2002).49 (Modin et al, Sweden, 2009)50 (Vedel 2009 Ageing clinical and experimental research?)51 (NHS national service framework for older people).52 PGEU Statement: COMMUNITY PHARMACISTS’ CONTRIBUTION TO ENSURING RATIONALAND SAFE USE OF MEDICINES BY OLDER PEOPLE; Approved by the PGEU General Assembly on 10 March 200953 (Spinewine & Mallet, 2003; Spinewine et al., 2005; Spinewine et al., 2007; Spinewine, 2006).54 (Gallagher, Ryan, Byrne, Kennedy, & O'mahony, 2008; O'Mahony & et alli, 2010; Lewis, 2005).55 (Krska & Onvolledig, 2001; Lewis, 2005; Spinewine, Dumont, Mallet, & Swine, 2006; Lenaghan, Holland, & Brooks, 2007; Kaboli, Hoth, McClimon, & Schnipper, 2006).56 (Spinewine et al., 2010).

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While improving and reorganizing older person’s care in modern health systems has become a priority in order to cope with the specific challenges of meeting the needs of older persons, the gap between conceptual models of care and existing provider practice remains wide. Implementations of innovative elderly care models is challenging. For example, despite strong evidence of the efficacy of integrated services in optimizing resource utilization and health and satisfaction levels among older persons, it has been difficult to diffuse and sustain these programs, in large part because of difficulties encountered securing the participation of healthcare professionals and, in particular, GPs21.

Develop research on multimorbidity in primary care. This kind of research is rare as shown in a review by Fortin et al 2005 22 There is need for research on more generic and patient centred outcome measures. In this very old patients the classical outcome measure of five-years survival percentage is simply ridiculous, and has to be changed in other outcome measures as degree of autonomy (related to degree of disability, diminished functionality) and quality of life. Qualitative research at this point is important. For instance qualitative research on mobility from the perspective of elderly indicates they have a different meaning of mobility compared to health professionals. It encompasses eq autonomy, independence and other factors ) (ref via M hasseler) .

Develop transitional programs and researchModels have been developed in silo either within primary care (eg. CCM, patient-centered medical home) or within hospitals (eg, elder friendly hospitals). Although these models are essential, the question remains: how to improve the transitions of older patients between primary and secondary care? There are a few research on this topic (see Naylor23). These research have been conducted in USA. I do not think there is any of this kind of research in Europe (?)

21 Reuben DB: Organizational interventions to improve health outcomes of older persons. Med Care 2002, 40:416-428Wolff JL, Boult C: Moving beyond round pegs and square holes: restructuring Medicare to improve chronic care. Ann Intern Med 2005, 143:439-445.Beland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, Dallaire L: A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2006, 61:367-473.Johri M, Beland F, Bergman H: International experiments in integrated care for the older persons: a synthesis of the evidence. Int J Geriatr Psychiatr 2003, 18:222-235.Newcomer R, Harrington C, Kane R: Challenges and accomplishments of the second-generation social health maintenance organization. Gerontologist 2002, 42:843-852.22 Fortin M, Lapointe L, Hudon C, Vanasse A. Multimorbidity is common to family practice. Is it commonly researched? Can Fam Physician 2005;51:244-24523 Naylor MD, Feldman PH, Keating S, Koren MJ, Kurtzman ET, Maccoy MC, Krakauer R. Translating research into practice: transitional care for older adults. J Eval Clin Pract. 2009 Dec;15(6):1164-70.

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