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

Roberto Bernabei, M.D.Roberto Bernabei, M.D.Centro di Medicina dell’ Invecchiamento Centro di Medicina dell’ Invecchiamento

Università Cattolica del Sacro Cuore - RomaUniversità Cattolica del Sacro Cuore - Roma

XXVIII Seminario dei Laghi

I SERVIZI SANITARI IN RETEDAL TERRITORIO ALL’OSPEDALE

AL TERRITORIO

Gardone Riviera – Brescia, 20 ottobre 2006

Malato Anziano FragileMalato Anziano FragileComorbiditàPoliterapiaStato funzionaleStato cognitivoFunzione fisicaTono dell’UmoreStato socialeIncontinenza

Malnutrizione

Cadute

Osteoporosi

FR

AG

ILIT

A’

FR

AG

ILIT

A’

Con quale modello Con quale modello assistenzialeassistenziale

Con quale Con quale metodologiametodologia

Sperimentazione modelli Sperimentazione modelli innovativi in Italia (1990-innovativi in Italia (1990-

2006)2006)BergamoMonza

Vittorio VenetoVenezia

ChiavariArezzo

Regione Umbria

Roma C

CastrovillariRagusaRegione Sicilia

LecceBrindisiBariFoggiaAndria

Regione Basilicata

Olbia

Jesi, Macerata, PesaroRegione Marche

Regione Molise

Avellino

Pescara

Rovereto

1 2Odds Ratio

SolitudiSolitudinene

Età 65-74 75-84 85+

P. economiciP. economiciDiagnosi 1-2 3-4 5+P. ospedaliz.P. ospedaliz.

2004;57:832-2004;57:832-836836

OSPEDALE OSPEDALE

TERRITORIOTERRITORIO

Modello Modello OrganizzatiOrganizzati

vovo

VMDVMD

HEALTH SETTINGSHEALTH SETTINGS

(GP, Hospital, NH, HC)(GP, Hospital, NH, HC)

Organization CGA

ELDERLY PEOPLE

Hospital

Home

CARE PLAN

General Practitioner +Case Manager + Community Geriatric Evaluation Unit

Eligible

Community Geriatric

Evaluation Unit

(Case Manager)

General Practitioner

Nursing homeHospitalDay hospitalHome care

Bernabei et al, Br Med J 1998; 316:1348-51

* p < 0.01

* * * *

Bernabei et al, Br Med J 1998; 316:1348-51

Functional status after 1 year of follow-up

Institutionalisation(hospital + nh)

Months

Treated

Control

HEALTH SETTINGSHEALTH SETTINGS

(GP, Hospital, NH, HC)(GP, Hospital, NH, HC)

Organization CGA

interRAI

North AmericaCanada

US

Nordic CountriesIceland, Norway, Sweden, Denmark, Finland

EuropeNetherlands, Germany,

Switzerland, France, UK

Italy, Spain,

Czech Republic

AustralasiaJapan, South Korea, Taiwan, Hong Kong

Australia, New Zealand

Middle East

Israel

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 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 ESPERIENZA ASL BERGAMOASL BERGAMO

Media indici funzionali (12 mesi)Media indici funzionali (12 mesi)

0 20 40 60

CP

SIA

DL

AD

L

Media giorni di degenza in ospedaleMedia giorni di degenza in ospedale

p vs. trattati < 0.001 p vs. trattati < 0.001 *TrattatiTrattati ControlliControlli

0 10 20 30

*

*

Per

pers

ona

Per

rico

vero

Landi F. et al., JAGS 2001;49:1288-1293

*

*

Time before hospitalisation

4003002001000

1,0

,9

,8

,7

,6

Treated

ControlP=0.05 (log rank test)

Hospitalization during follow-up

Landi F. et al., JAGS 2001;49:1288-1293

0 10 20 30Media giorni di degenza in ospedale

p vs. trattati < 0.001 *Trattati Controlli

*

*

Per

per

sona

Per

ric

over

o

Landi F. et al., J Clin Epidemiol 2001;54:968-70

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

Comprehensive Geriatric Assessment

Patient level

Population level Database

Prognostic factors

Outcome measurements

Quality control indicators

Make the physical exam complete

Better care plan

Comparisons

Developing an evidence-base for community care services in Europe

The Aged Home Care projectADHOC

Monza (I)

Prague(CZ)

Helsinki (FIN)

Amiens (F)

Copenaghen (DK)

Maidstone Ashford(UK)

Amsterdam (NL)

Reykjavik(IS)

Oslo (N)

Stockholm(S)

NurnbergBayreuth(D)

Monza Monza (I)(I)

Prague Prague (CZ)(CZ)

Helsinki Helsinki (FIN)(FIN)

Amiens Amiens (F)(F)

CopenaghCopenaghen (DK)en (DK)

MaidstonMaidstone e AshfordAshford (UK)(UK)

Amsterdam Amsterdam (NL)(NL)

ReykjaviReykjavik (IS)k (IS)

Oslo (N)Oslo (N)

StockholStockholm (S)m (S)

Bielefeld Bielefeld (D)(D)

interRAI

Minimum Data Set for Home Minimum Data Set for Home CareCare- CognitionCognition- Communication/HearingCommunication/Hearing- VisionVision- Mood and BehaviourMood and Behaviour- Social FunctioningSocial Functioning- Informal support servicesInformal support services- Physical functioningPhysical functioning- ContinenceContinence- Disease diagnosesDisease diagnoses- Health statusHealth status- Preventive health measuresPreventive health measures- Nutrition/Hydration statusNutrition/Hydration status- Dental statusDental status- Skin conditionSkin condition- Enviromental AssessmentEnviromental Assessment- Service UtilisationService Utilisation

European Home Care Services European Home Care Services (EUHCS) assessment form(EUHCS) assessment form

Setting:Setting:- Demographic characteristics Demographic characteristics - Hospital and nursing care bedsHospital and nursing care beds

Service structures:Service structures:- Financial structuresFinancial structures- Management structuresManagement structures- Range and organization of services Range and organization of services providedprovided

Service delivery:Service delivery:- Eligibility criteriaEligibility criteria- Referral systemsReferral systems- Provision of integrated serviceProvision of integrated service- Health/social professionals and Health/social professionals and administrative personnel per patientadministrative personnel per patient- Total number of patients per yearTotal number of patients per year- Mean duration of service provision Mean duration of service provision per patientper patient- Days per week of service provisionDays per week of service provision- Night and respite care servicesNight and respite care services- Waiting lists availabilityWaiting lists availability- Use of any validated assessment Use of any validated assessment instrumentsinstruments- Application of any specific Application of any specific guidelineguideline

Death registriesDeath registries

Health Services UseHealth Services Use

- ER- ER

- Hospital and nursing home- Hospital and nursing home

Case ManagerCase Manager

No Case No Case ManagerManager

Log rank < Log rank < 0.0010.001

00 33 66 99 1122

Case Manager e Case Manager e Istituzionalizzazione in Istituzionalizzazione in

RSARSA

On

der

G, L

and

i F. J

AG

S, i

n p

ress

On

der

G, L

and

i F. J

AG

S, i

n p

ress

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

0 5 10 15 20 25

Monza

Prague

Copenhagen

Helsinki

Amiens

Reykjavik

Amsterdam

Stockolm

Ashford/Maidstone

Oslo

Nuremberg/Bayreuth

Cit

ies

Total score

Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

Factor analysisFactor 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

Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press

1,000000,00000-1,00000-2,00000

REGR factor score 1 for analysis 2

1,00000

0,00000

-1,00000

-2,00000

RE

GR

fac

tor

sc

ore

2

fo

r an

aly

sis

2

11

10

9

8

7

6

5

4

3

2

1

2

1

3

IT

IS UK

D

CZ

F

NL

DKFI

NO

S

The combination of these two factors shows 3 models of care:The combination of these two factors shows 3 models of care:

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 L’assistenza all’anziano fragile - situazione attualefragile - situazione attuale

OSPEDALE (Azienda)

DIVISIONI PER ACUTI

DISTRETTO

UVG (UOD)

RSA AD (ADI) C.DIURNI

… … in futuroin futuro

AZIENDA OSPEDALE

DIVISIONI PER ACUTI

DIVISIONI POST ACUTI

RSA

DISTRETTO

UVG (UOD)

RSA AD (ADI) C.DIURNI

CASE CASE MANAGERMANAGER +