Presentazione di PowerPoint

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XXVIII Seminario dei Laghi
I SERVIZI SANITARI IN RETE DAL TERRITORIO
ALLOSPEDALE 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
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Malato Anziano Fragile
Comorbidità
Politerapia
Con quale modello assistenziale

• Stato funzionale
• Stato cognitivo
• Funzione fisica
• Tono dellUmore
• Stato sociale

FRAGILITA
Incontinenza
Malnutrizione
Con quale metodologia
Cadute
Osteoporosi
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Sperimentazione modelli innovativi in Italia
(1990-2006)
Rovereto
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200457832-836
Età 65-74 75-84 85
Solitudine
P. economici
Diagnosi 1-2 3-4 5
P. ospedaliz.
1
2
Odds Ratio
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OSPEDALE TERRITORIO
Modello Organizzativo
VMD
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HEALTH SETTINGS (GP, Hospital, NH, HC)
Organization CGA
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(No Transcript)
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General Practitioner
Home
ELDERLY PEOPLE
Community Geriatric Evaluation Unit (Case
Manager)
Hospital
Eligible
CARE PLAN General Practitioner Case Manager
Community Geriatric Evaluation Unit
Nursing home
Hospital
Day hospital
Home care
Bernabei et al, Br Med J 1998 3161348-51
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Functional status after 1 year of follow-up
Bernabei et al, Br Med J 1998 3161348-51
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Institutionalisation (hospital nh)
Treated
Control
Months
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HEALTH SETTINGS (GP, Hospital, NH, HC)
Organization CGA
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interRAI
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Home Care BERGAMO District 1 95
patients District 2 92 patients
Randomisation District 1 and District 2
Landi F. et al., JAGS 2001491288-1293
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Use of Home Care (1-year of follow-up) in the
treated and control groups
Landi F. et al., JAGS 2001491288-1293
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ESPERIENZA ASL BERGAMO

Per ricovero
CPS

IADL
ADL
Per persona


0
10
20
30
Media indici funzionali (12 mesi)
Media giorni di degenza in ospedale

p vs. trattati lt 0.001
Trattati
Controlli
Landi F. et al., JAGS 2001491288-1293
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Hospitalization during follow-up
Landi F. et al., JAGS 2001491288-1293
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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 ricovero

Per persona
Media giorni di degenza in ospedale

p vs. trattati lt 0.001
Trattati
Controlli
Landi F. et al., J Clin Epidemiol 200154968-70
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Comprehensive Geriatric Assessment
Make the physical exam complete Better care plan
Patient level
Prognostic factors
Outcome measurements
Population level
Database
Quality control indicators
Comparisons
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Developing an evidence-base for community care
services in EuropeThe Aged Home Care
projectADHOC
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interRAI
Copenaghen (DK)
Oslo (N)
Reykjavik (IS)
Helsinki (FIN)
Amsterdam (NL)
Stockholm (S)
Maidstone Ashford (UK)
Prague (CZ)
Amiens (F)
Bielefeld (D)
Monza (I)
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• 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

• 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

Death registries Health Services Use - ER -
Hospital and nursing home
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Case Manager e Istituzionalizzazione in RSA
Case Manager
No Case Manager
Onder G, Landi F. JAGS, in press
Log rank lt 0.001
12
0
3
6
9
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Relationship between mean MDS HC IADL index and
mean MDS ADL hierarchy score by country
Carpenter I et al, Aging Clin Exp Res
200416259-269
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Relationship between mean MDS Cognitive
Performance Scale and mean MDS ADL hierarchy by
country
Carpenter I et al, Aging Clin Exp Res
200416259-269
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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(AdHoc)
  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
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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
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Score distribution of the integration index among
participating cities
Henrard JC, Bernabei R, et al. Int J Integrated
Care 2006 in press
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Factor analysis

• 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
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The combination of these two factors shows 3
models of care
2
1
UK
IS
NO
FI
S
D
IT
DK
NL
CZ
3
F
Henrard JC, Bernabei R, et al. Int J Integrated
Care 2006 in press
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• 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
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Lassistenza allanziano fragile - situazione
attuale
DISTRETTO UVG (UOD) RSA AD (ADI) C.DIURNI
OSPEDALE (Azienda) DIVISIONI PER ACUTI
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in futuro
DISTRETTO UVG (UOD) RSA AD (ADI)
C.DIURNI
AZIENDA OSPEDALE DIVISIONI PER ACUTI DIVISIONI
POST ACUTI RSA
CASE MANAGER