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La sanità in rete: un ponte tra medicina delle evidenze e mondo reale Roberto Bernabei, M.D. Centro di Medicina dell Invecchiamento Università Cattolica.

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Presentazione sul tema: "La sanità in rete: un ponte tra medicina delle evidenze e mondo reale Roberto Bernabei, M.D. Centro di Medicina dell Invecchiamento Università Cattolica."— Transcript della presentazione:

1 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 XXVIII Seminario dei Laghi I SERVIZI SANITARI IN RETE DAL TERRITORIO ALLOSPEDALE AL TERRITORIO Gardone Riviera – Brescia, 20 ottobre 2006

2 Malato Anziano Fragile Comorbidità Politerapia Stato funzionale Stato cognitivo Funzione fisica Tono dellUmore Stato sociale Incontinenza Malnutrizione Cadute Osteoporosi FRAGILITA Con quale modello assistenziale Con quale metodologia

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

4 12 Odds Ratio Solitudine Età P. economici Diagnosi P. ospedaliz. 2004;57:

5 OSPEDALETERRITORIO Modello Organizzativo VMD

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

7

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

9 * p < 0.01 **** Bernabei et al, Br Med J 1998; 316: Functional status after 1 year of follow-up

10 Institutionalisation (hospital + nh) Months Treated Control

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

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

13 Home Care BERGAMO District 1 = 95 patients District 2 = 92 patients Randomisation District 1 and District 2 District 1 - MDS-HC (Barthel, MMSE,Lawton to compare outcomes) 4 patients refuse District 2 - Geriatric Assessment with Barthel, MMSE, Lawton 2 patients refuse 3 patients died2 patients died88 patient completed 1 year of follow-up Landi F. et al., JAGS 2001;49:

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

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

16 Hospitalization during follow-up Landi F. et al., JAGS 2001;49:

17 Media giorni di degenza in ospedale p vs. trattati < * TrattatiControlli * * Per persona Per ricovero Landi F. et al., J Clin Epidemiol 2001;54: 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

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

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

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

21 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 - Application of any specific guideline Death registries Health Services Use - ER - ER - Hospital and nursing home - Hospital and nursing home

22 Case Manager No Case Manager Log rank < Case Manager e Istituzionalizzazione in RSA Onder G, Landi F. JAGS, in press

23 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:

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

25 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

26 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

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

28 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

29 2 1 3 IT IS UK D CZ F NL DK FI NO S The combination of these two factors shows 3 models of care:

30 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

31 Lassistenza allanziano fragile - situazione attuale OSPEDALE (Azienda) DIVISIONI PER ACUTI DISTRETTO UVG (UOD) RSA AD (ADI) C.DIURNI

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


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