XXVIII Seminario dei Laghi I SERVIZI SANITARI IN

XXVIII Seminario dei Laghi I SERVIZI SANITARI IN RETE DAL TERRITORIO ALL’OSPEDALE AL TERRITORIO La sanità in rete: un ponte tra medicina delle evidenze e mondo reale Roberto Bernabei, M. D. Centro di Medicina dell’ Invecchiamento Università Cattolica del Sacro Cuore - Roma Gardone Riviera – Brescia, 20 ottobre 2006

FRAGILITA’ Malato Anziano Fragile Comorbidità Politerapia Stato funzionale ØStato cognitivo ØFunzione fisica ØTono dell’Umore ØStato sociale Con quale modello assistenziale Incontinenza Malnutrizione Cadute Osteoporosi Con quale metodologia

Sperimentazione modelli innovativi in Italia (1990 -2006) Bergamo Monza Rovereto Vittorio Veneto Venezia Jesi, Macerata, Pesaro Regione Marche Lecce Regione Umbria Chiavari Brindisi Arezzo Pescara Bari Foggia Roma C Olbia Andria Regione Molise Basilicata Avellino Ragusa Castrovillari Regione Sicilia

2004; 57: 832 -836 Età 65 -74 75 -84 85+ Solitudine P. economici Diagnosi 1 -2 3 -4 5+ P. ospedaliz. 1 Odds Ratio 2

OSPEDALE Modello Organizzativo VMD TERRITORIO

HEALTH SETTINGS (GP, Hospital, NH, HC) Organization CGA

General Practitioner Home ELDERLY PEOPLE Community Geriatric Evaluation Unit (Case Manager) Hospital Eligible CARE PLAN General Practitioner +Case Manager + Community Geriatric Evaluation Unit Home care Day hospital Hospital Nursing home Bernabei et al, Br Med J 1998; 316: 1348 -51

Functional status after 1 year of follow-up * * * p < 0. 01 Bernabei et al, Br Med J 1998; 316: 1348 -51

Institutionalisation (hospital + nh) Treated Control Months

HEALTH SETTINGS (GP, Hospital, NH, HC) Organization CGA

inter. RAI Nordic Countries Iceland, Norway, Sweden, Denmark, Finland North America Canada US Middle East Israel Europe Netherlands, Germany, Switzerland, France, UK Italy, Spain, Czech Republic Australasia Japan, South Korea, Taiwan, Hong Kong Australia, New Zealand

Home Care BERGAMO District 1 = 95 patients District 2 = 92 patients Randomisation District 1 and District 2 District 1 - MDS-HC District 2 - Geriatric Assessment with (Barthel, MMSE, Lawton to compare outcomes) 2 patients refuse Barthel, MMSE, Lawton 4 patients refuse 3 patients died 88 patient completed 1 year of follow-up 2 patients died 88 patient completed 1 year of follow-up Landi F. et al. , JAGS 2001; 49: 1288 -1293

Use of Home Care (1 -year of follow-up) in the treated and control groups Landi F. et al. , JAGS 2001; 49: 1288 -1293

Per ricovero * * Media indici funzionali (12 mesi) Trattati * Per persona ADL IADL CPS ESPERIENZA ASL BERGAMO 0 * 10 20 30 Media giorni di degenza in ospedale Controlli * p vs. trattati < 0. 001 Landi F. et al. , JAGS 2001; 49: 1288 -1293

Hospitalization during follow-up 1, 0 Treated , 9 , 8 , 7 Control P=0. 05 (log rank test) , 6 0 100 200 300 400 Time before hospitalisation Landi F. et al. , JAGS 2001; 49: 1288 -1293

A new model of integrated home care for the elderly: impact on hospital use. Landi F. , Onder G. , Russo A. , Tabaccanti S. , Rollo R. , Federici S. , Tua E. , Cesari M. , Bernabei R Per persona Per ricovero * * Media giorni di degenza in ospedale Trattati Controlli * p vs. trattati < 0. 001 Landi F. et al. , J Clin Epidemiol 2001; 54: 968 -70

Comprehensive Geriatric Assessment Patient level Make the physical exam complete Better care plan Prognostic factors Population level Database Outcome measurements Quality control indicators Comparisons

Developing an evidence-base for community care services in Europe The Aged Home Care project ADHOC

inter. RAI Reykjavik (IS) Copenaghen (DK) Oslo (N) Helsinki (FIN) Amsterdam (NL) Maidstone Ashford (UK) Stockholm (S) Prague (CZ) Amiens (F) Monza (I) Bielefeld (D)

Minimum Data Set for Home Care - Cognition - Communication/Hearing - Vision - Mood and Behaviour - Social Functioning - Informal support services - Physical functioning - Continence - Disease diagnoses - Health status - Preventive health measures - Nutrition/Hydration status - Dental status - Skin condition - Enviromental Assessment - Service Utilisation Death registries Health Services Use - ER - Hospital and nursing home European Home Care Services (EUHCS) assessment form Setting: - Demographic characteristics - Hospital and nursing care beds Service structures: - Financial structures - Management structures - Range and organization of services provided Service delivery: - Eligibility criteria - Referral systems - Provision of integrated service - Health/social professionals and administrative personnel per patient - Total number of patients per year - Mean duration of service provision per patient - Days per week of service provision - Night and respite care services - Waiting lists availability - Use of any validated assessment instruments - Application of any specific guideline

Case Manager e Istituzionalizzazione in RSA No Case Manager Log rank < 0. 001 0 3 6 9 12 Onder G, Landi F. JAGS, in press Case Manager

Relationship between mean MDS HC IADL index and mean MDS ADL hierarchy score by country Carpenter I et al, Aging Clin Exp Res 2004; 16: 259 -269

Relationship between mean MDS Cognitive Performance Scale and mean MDS ADL hierarchy by country Carpenter I et al, Aging Clin Exp Res 2004; 16: 259 -269

Proposal of a service delivery integration index of home care for older persons: application in several European cities • To propose an integration index of home care delivery to older persons, to study its validity and to apply it to home care services of European cities; • Data are from the “the Aged in Home care”(Ad. Hoc) study, which includes data on older adults in home care in: Czech Republic, Denmark, UK, Finland, France, Germany, Iceland, Italy, the Netherlands, Norway and Sweden. Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

Integration Index (29 items) • Comprehensive geriatric assessment • Multidisciplinary team approach • Team meeting for care planning • Case manager • Participation of GP to team meeting • Day and night service provision • Weekend provision • Single entry point • Hospital discharge management • Decubitus care • Catheter management • Intra venous medication • Nutritional therapy • Suctioning • Therapies (occupational, speech, psycho-social and, physiotherapy) • Assistance for five instrumental activities of daily living (cooking, shopping, cleaning, laundry, meals on wheels) • Assistance for three activities of daily living (ADL: feeding, bathing, dressing) • Assistance for two surveillance items (supervision, tele-help) Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

Score distribution of the integration index among participating cities Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

Factor analysis shows two factors accounting for 51% of total variance: Factor 1. including working arrangements facilitating integration of services provided (i. e. CGA, case manager, team meeting, multidisciplinary approach); Factor 2. including mostly items related to social and health care Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

The combination of these two factors shows 3 models of care: 2 IS UK 1 NO S D IT FI DK NL CZ 3 F Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

1. Extensive social and health care with very little integration of services (Oslo, Stockholm, Helsinki, Copenhagen and Amsterdam); 2. Integration of services and few or no social and health care delivery (Monza, Reykjavik and Ashford/Maidstone). 3. Few social and health care delivery and few or no integration (Amiens and Prague). Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

L’assistenza all’anziano fragile - situazione attuale DISTRETTO OSPEDALE (Azienda) UVG (UOD) DIVISIONI PER ACUTI RSA AD (ADI) C. DIURNI

… in futuro DISTRETTO AZIENDA OSPEDALE DIVISIONI PER ACUTI CASE MANAGER + UVG (UOD) DIVISIONI POST ACUTI RSA AD (ADI) C. DIURNI