International experiments in integrated care for the elderly: a synthesis of the evidence
Johri M, Beland F and Bergman H;
Commented by , 30 Apr 2003
Aims of the Study
1. to examine the evidence for innovative schemes in developed countries to promote deinstitutionalisation and community-based care for the elderly.
2. to identify common features of an effective system of integrated care.
3. to examine the potential of such models to positively affect care of the elderly and public finances.
Background
Institutional care for older people is expensive, and usually not wanted by older people. Various international programmes have attempted to provide integrated community care instead of institutional care; this study sought to identify, describe and analyse these demonstration programmes, as part of a theme issue on Long Term Care in the March issue of the International Journal of Geriatric Psychiatry.
Method
Candidate demonstration programmes were identified by a Medline/Pub Med literature search from 1966 – 2000. Studies of inclusion were narrowed down to those implementing community-based reform measured against a comparison group, aiming at integration of acute and long term care services.
As a result of this literature search, 5 demonstration sites/programmes are described in detail in the paper:
1. Darlington (UK)
2. On Lok (Chinatown, San Francisco) – this study was extended to 24 other sites in the USA, entitled the Programme of All-Inclusive Care for the Elderly (PACE)
3. Social Health Maintenance Organisations (USA)
4. Rovereto and Vittorio Veneto (Italy)
5. SIPA programme (Montreal)
Space constraints do not allow description of these programmes in detail here, readers are encouraged to read the original paper.
Results
Analysis of the above programmes led the authors to conclude that, in some circumstances, community-based care can impact favourably on rates of institutionalisation and costs. This depends on the whole system. The authors identify common design features necessary for success:
1. Case management, geriatric assessment, and a multidisciplinary team – long term case management was particularly emphasised in the Darlington model.
2. Single Point of Entry – none of the USA models employed this, reflecting the nature of the multiple payer healthcare system in the USA. A clear advantage for the other models, which all used single point of entry, was identified.
3. Financial Levers – financial incentives to promote community care are of critical importance, and were used by all the programmes except the Italian site. Interestingly, the Italian site achieved good results without financially supporting the community care programme.
Discussion
This study purports to show, via a evidence-based approach, that the development of cost-effective, integrated systems of care for community support of frail elderly people is possible. The authors acknowledge that the challenge is generalisation beyond the demonstration phase to national expenditure and quality of care.
To date, the only reform initiatives successfully implemented on a larger scale are single point of entry into geriatric assessment and case management in publicly funded systems of care, which have been adopted in Italy and Canada. A strength of this model is the ability to serve clients in rural areas.