Howard Bergman MD, FCFP, FRCPC

Chair, Department of Family MedicineProfessor of Family Medicine, Medicine and Oncology

The Dr. Joseph Kaufmann Professor of Geriatric Medicine McGill University

The Complexity of Care for Older Persons

Howard Bergman, MD, FCFP, FRCPC

Chair, Department of Family Medicine

Professor of Family Medicine, Medicine and Oncology

The Dr. Joseph Kaufmann Chair of Geriatric MedicineMcGill University

17.3.12

Family MedicineMédecine de famille

The Complexity of Care for Older Persons

The Shifting Face of Health Care

From acute to chronic disease

From institutions to networks of care; from a single site (hospital, nursing home) to many sites: home, assisted living, supportive housing, physician’s office, community clinics, ambulatory care centers, community hospitals, academic health centers, rehabilitation facilities, nursing homes, palliative care centers

From a single professional, generally a physician to many health care professionals: family doctors, specialists, nurses, physical therapists, nutritionists, social workers, psychologists, etc.

Expectations/knowledge/Involvement of patients and family

The Shifting Face of Health Care

↑ Complexity↑ Interdependency↑ Uncertainty Increasing preoccupation with costs and

performance leading to increased government intervention/control/reform

Continuous Change

Health care systems and the challenge of aging

↑ old, old-old↑ life expectancy

– In developing countries as well: sanitation, nutrition, living conditions, education, infectious disease control, med care

↑ chronic diseases– In developing countries as well: ↑ life expectancy, changes in

nutrition, physical activity, ↑ tobacco, med care↑ chronic diseases +↑ life expectancy

= Aging with ↑ disability

Bovet P. Tropical Medicine and International Health 2001

Heath care systems and the challenge of aging

Potential for promotion/prevention promoting healthy aging and in at least delaying onset of frailty and disability – Interaction: health/functional status/social status and support– Importance of chronic disease and impact on quality of life and

progression to disability

↑ complex interventions (technology/medication) in increasingly older persons

Health care systems poorly adapted to the management of chronic disease, frailty and dependency; complexity of treating chronic diseases and frail older persons

16%(n=8)

30% (n=15)

42% (n=21)

12% (n=6)

0

20

40

60

80

100

Without frailtymarkers or IADL /

ADL disability

With frailtymarkers but

without IADL /ADL disability

IADL disabledwithout ADL

disability

ADL disabled

%

Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H.Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for chemotherapy Journal of Gerontology; Medical Sciences (In Press)

Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy- preliminary findings

Comorbidities ADL dependency

Frailty

MonitoringIntervention

médicaleMonitoring

Multidisciplinary care

MonitoringPrevention

Health promotion/prevention

ScreeningAcute care

Complex care

Focus on very frail older persons with disabilities

Generally over 75Disabilities in ADL/IADLAcute and chronic medical problemsImportance of social networkFrequent transitions, high utilisation and costs:

community, hospital, rehab, NH– 20% of older persons=3% population=30% costs

Need for a complex combination of medical and social services-acute and continuing care

Focus on integration of care for very frail older persons with disabilities

Increase in number of older persons and costs of carePresent difficulty in management

– Fragmentation; unmet needs; underutilization of effective geriatric and care management interventions; parallel play-medical, community services; problem in quality of care; negative incentives; inappropriate use of resources ; absence of “comprehensive” responsibility and accountability

Increasing evidence of the effectiveness of treatment and care management in frail older persons

Integration/CoordinationProjects

InternationalPace/On Lok (USA)S/HMO (USA)Bernabei (Italy)British experience-MatronsCOPA-Paris

CanadaCHOICERISCBois-Francs/PRISMA SIPA

SIPA characteristics

Objective: improve health and functional status, quality, satisfaction; decrease inappropriate hospital and nursing home care; control costs

Primary care responsible/accountable for a defined population Integrate/coordinate health, social and supportive care Utilisation of protocols Case management with more responsive care Align governance and financial incentives with clinical goals

Bergman, Béland, Lebel et al CMAJ. 1997; 157:1116-1121 Béland, Bergman, Lebel et al J of Gerontol, Med Sci. 2006,vol 61A, No. 4, 367–373

Clinical approach

A person centred approach based on health/functional status for older persons with multiple chronic diseases/disabilities/difficult social context/end of life

Geriatric assessment based on health/functional/social/environmental needs and not only on allocation of resources – Interdisciplinary for detection and mangement of

geriatric syndromes and chronic disease– Intensive case-management

Multidisciplinary team responsible for assessing needs, organizing and delivering most of health and social services in community in collaboration with primary care physician

Comprehensive geriatric assessment on entryEvidence based interdisciplinary protocols

– Initial assessment, Nutrition, falls, CHF, dementia, depression, medication, vaccination

Rapid communication and mobilisation of resources– Intensive home care, group homes

24 hour nurse on call with MD backup

SIPA InterventionAssessment and management

Beland, Bergman, Lebel, Clarfield et al: A System of Integrated Care for Older Persons With Disabilities in Canada: Results From a Randomized Controlled Trial. Journal of Gerontology: med sciences 2006

Consolidated case management with multidisciplinary team

Intervention with patients and caregiversLiaison with family MD and specialistsMaintain clinical responsibilityActively followed patients throughout

trajectory of care including in hospital– Assure continuity– Ease transitions

SIPA InterventionCase Management

Principal SIPA Impact↓ utilization of hospital and SNH utilization in SIPA group

– As expressed by the ↓ combined costs of hospital and SNH– Driven by decreased ALC “admission”; ↓ N.S. differences in utilization

in other areas such as ED

↓ hospital utilization for those with increased ADL disability↓ use of hospital as conduit for SNH placementDelaying SNH placement for those with few chronic diseases

(lesser risk) and those living alone (higher risk)Cost neutral

Beland, Bergman, Lebel, Clarfield et al: A System of Integrated Care for Older Persons With Disabilities in Canada: Results From a Randomized Controlled Trial.

Journal of Gerontology: med sciences 2006

Major trials on integrated care:Results

Major (yet incomplete) innovations and transformations in clinical model and management of care with modest addition of resources

Feasibility/impact of clinical/utilisation responsibilityThe potential to change the configuration of utilization

of services with at least no increase in over all costsWhile maintaining or improving quality and

satisfactionFor those older persons with moderate/severe

disability of the population who need a complex combination of health and social services

Beyond the ModelsReflections on key elements

Primary CareIntegration et coordinationCoordination with specialty careGovernance/IncentivesOlder person/family/community

Beyond the ModelsReflections on key elements

Primary careWhat seems to work/needs to be testedPrimary med care:

org/infrastructure/remunerationThe multi disciplinary care

integrated into primary medical care

Evolution of relationships among professionals

Rapid/flexible response and accessibility

Rapid access to intensive professional services (professional and social); access to a wide range of assisted/supportive housing

Population data/ responsibility

What does not seem to workPrimary med care: organization

/infrastructure/remuneration not suited to complex continuing care

The programmatic, budgetary and geographic cleavage between primary medical and multidisciplinary care

Parallel play among professionalsSporadic responsibilityThere are no emergencies

Beyond the ModelsReflections on key elements

Integration/Coordination

What seems to work/needs to be tested

Integration/coordination based upon clinical objectives in primary care

Geriatric evaluation/intervention based on health, social, environmental needs as well as allocation of services– Management of chronic diseases

and geriatric syndromes– Secondary prevention/early

intervention: mobility, falls, dementia etc

What does not seem to workCoordination as an objective in

itself objectivecoordination based on the

existing way of doing things; evaluation principally to allocate

services/budget Coordination detached from

primary medical care

Beyond the ModelsReflections on key elements

coordination with specialty care

What seems to work/needs to be tested

Primary medical care closely coordinated with specialty services, in particular geriatrics

Rapid access between primary care and specialty/diagnostic services/hospital

Community geriatric consultation and management

Geriatric evaluation before placement

What does not seem to workEpisodic hospital restricted

geriatric evaluation and consultation

Complicated Access between specialty services and primary care

ER as entry point

Implementation in a coherent system: challenges to exploreSpecialised geriatric medicine programs

Beyond the traditional hospital role– Optimise acute care for older persons on all wards; acute

geriatrics programs for targeted patients– reorientation– Sub acute and Rehab– Research/teaching/training

The development of a new vision of hospital based geriatrics open to the community– Regional geriatric programs– Community geriatric assessment teams

Beyond the ModelsReflections on key elements

governance/incentives

What seems to work/needs to be testedGovernance, appropriate budget

incentives based on partnership, joint planning and even joint financing which support clinical objectives

Clinician leadership at clinical and administrative level

Entrepreneurial management based on objectives: quality, results and accountability

Accountability based on systemic markers: health and functional status; utilisation throughout the trajectory of care

What does not seem to workPretend that incentives and

budget are not importantFragmented responsibilityAccountability based on the

number of acts/hours Control top down management

Beyond the ModelsReflections on key elements

Older person/family/community

What seems to work/needs to be tested

Dignity, independence, empowerment

ChoiceCaring for the caregiverEngaging patient, family

and community

What does not seem to workForget that patients and families

are intelligent and devoted

The Challenge of Change

A vision for change based on emerging local and national solutions, on evidence and on international experience

Adapt; do not adopt Partnership: clinicians, managers, researchers,

the community Role of research:

– Synthesising evidence– Population and practice based studies– Evaluative research