La sanità in rete: un ponte tra medicina delle evidenze e mondo reale 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

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

Sperimentazione modelli innovativi in Italia (1990-2006) 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

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

Modello Organizzativo OSPEDALE TERRITORIO Modello Organizzativo VMD

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

General Practitioner Home ELDERLY PEOPLE Hospital Eligible CARE PLAN 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 * Bernabei et al, Br Med J 1998; 316:1348-51

Institutionalisation (hospital + nh) Treated Control Months

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

interRAI Nordic Countries North America Canada Europe Australasia 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

District 2 - Geriatric Assessment with Barthel, MMSE, Lawton 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 died 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

ESPERIENZA ASL BERGAMO * Per ricovero CPS * IADL ADL * Per persona * 10 20 30 Media indici funzionali (12 mesi) Media giorni di degenza in ospedale Trattati * Controlli p vs. trattati < 0.001 Landi F. et al., JAGS 2001;49:1288-1293

Hospitalization during follow-up Time before hospitalisation 400 300 200 100 1,0 ,9 ,8 ,7 ,6 Treated Control P=0.05 (log rank test) 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 ricovero * Per persona 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 Make the physical exam complete Better care plan Patient level Prognostic factors Outcome measurements Population level Database Quality control indicators Comparisons

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

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

- ER 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 - Hospital and nursing home

Case Manager e Istituzionalizzazione in RSA No Case Manager Onder G, Landi F. JAGS, in press Log rank < 0.001 3 6 9 12

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”(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

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 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 1 UK IS NO FI S IT D DK NL CZ 3 F Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

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 UVG (UOD) RSA AD (ADI) C.DIURNI OSPEDALE (Azienda) DIVISIONI PER ACUTI

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