Health care for older persons in Italy

The aging of the population, with the ensuing rise in the number of older "clients" of the Health Agencies (15.2% people aged 0-14 vs 16% of those aged 64+ already in 1993), the new prospective payment system and a corporate philosophy were the driving forces that led the local Health Agencies to redesign the long-term care system, shifting resources from the hospital to the community. This shift constitutes a present challenge to the entire National Health Service. Furthermore, the Italian Health Service is also becoming decentralized, reflecting closely the political and administrative division of Italy into twenty regions. Regional authorities assign the available resources according to local needs and often interpret the central government's directives for controlling their health care budgets at their own discretion. As a result, profound interregional differences in health care expenditure occur which may aggravate the pre-existing inequalities between the Italian regions. In the coming years, the main priorities to satisfy the needs of frail elderly people are the following: 1) to adapt the number of rehabilitation beds to the standard of 1 bed for 1000 inhabitants; 2) to guarantee in all Health Agencies the presence of Geriatric Evaluation Units in a position to: perform comprehensive geriatric assessment immediately upon request; design and implement individualized care plans in agreement with general practitioners; determine the services that patients are eligible for; and coordinate the delivery and facilitate the integration process between social and health care professionals; 3) to develop all possible alternatives to hospitalization, chiefly programs of integrated home health care or hospital at home; and 4) to realize the number of beds already funded in skilled nursing facilities (RSA) while decreasing acute beds to 4/1000.     

Geriatric assessment in the home.

Home assessment of health, environmental, and social factors, and their interactions that may impair the patient's functional capabilities and quality of life can play a critical role in the care of frail elderly patients. Home assessments can reveal important new health and social problems not identified in a clinical visit. Recent information suggests that home assessment is identified with good patient outcomes. Although this type of assessment is traditionally carried out by a nurse in the context of an interdisciplinary team, an individual primary care physician can also establish an ad hoc, multidisciplinary team to help care for frail elderly patients using principles derived from a comprehensive home assessment.     

Urban/rural differences in home health patients and services

Using data from the Wisconsin Annual Survey of Home Health Agencies, we describe urban/rural differences for home health care patients. Our findings indicate that urban dwellers are more likely to be home health patients than are rural residents. Urban home health patients are more apt to be nonelderly, male, and have "other conditions" as their primary diagnosis. They are also likely to be more physically dependent and to receive home care longer. Urban home health patients are more typical of long-term care patients, whereas rural patients may be better described as recipients of postacute care, often recovering from diabetes and heart attacks. Possible problems with rural access to home health care are discussed.     

Potentially reversible risk factors and urinary incontinence in frail older people living in community

BACKGROUND: urinary incontinence is a common problem among older people living in different community settings. The multifactorial origin of urinary incontinence has been largely addressed and many previous studies have identified several reversible factors associated with incontinence. However, few data exist concerning the potentially reversible causes of this condition among frail community-dwelling older individuals. OBJECTIVE: the aim of the present study is to estimate, in a large population of frail elderly people living in the community, the prevalence of urinary incontinence and to determine physical, social, and psychological factors associated with it. DESIGN: observational study. Subjects and methods: we analysed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home care programmes (n=5418). A total of 22 Home Health Agencies participated in this project evaluating the implementation of the Minimum Data Set for Home Care instrument. The main outcome measures were the prevalence and factors associated with urinary incontinence. RESULTS: urinary incontinence was recorded in 51% of patients, and it was more common in women than men (52% versus 49%, respectively; P=0.01). After adjustment for each of the variables considered in this study, three potentially reversible factors were strongly associated with urinary incontinence: urinary tract infection (adjusted odds ratio, 3.46; 95% confidence interval, 2.65-4.51), use of physical restraints (adjusted odds ratio, 3.20; 95% confidence interval, 2.19-4.68), environmental barriers (adjusted odds ratio, 1.53; 95% confidence interval, 1.15-2.02). These associations were consistent in both men and women. CONCLUSIONS: the major finding of our study is that potentially reversible factors were strongly and independently associated with urinary incontinence. Failure to make all reasonable efforts to assess and to treat all these factors among frail elderly people should be considered one of the most important indicators of poor quality of care.     

The house call: an important service for the frail elderly

There are many advantages in the performance of house calls by physicians for home bound, frail elderly patients: a needed service is provided; assessment of the "non-medical" aspects important in geriatric health care is readily accomplished; physician-patient relations will improve; the role of the physician as advisor and educator is emphasized; deep gratification to the physician results; and the physician will have better working relationships with other health professionals providing home services. House calls should be part of the curriculum of training programs. More house calls are advocated in order to provide quality care for the frail elderly and to offer them an option to institutionalization.     

Second and third generation assessment instruments: the birth of standardization in geriatric care

The systematic adoption of "second-generation" comprehensive geriatric assessment instruments, initiated with the Minimum Data Set (MDS) implementation in U.S. nursing homes, and continued with the uptake of related MDS instruments internationally, has contributed to the creation of large patient-level data sets. In the present special article, we illustrate the potential of analyses using the MDS data to: (a) identify novel prognostic factors; (b) explore outcomes of interventions in relatively unselected clinical populations; (c) monitor quality of care; and (d) conduct comparisons of case mix, outcomes, and quality of care. To illustrate these applications, we use a sample of elderly patients admitted to home care in 11 European Home Health Agencies that participated in the AgeD in HOme Care (AD-HOC) project, sponsored by the European Union. The participants were assessed by trained staff using the MDS for Home Care, 2.0 version. We argue that the harmonization by InterRAI of the MDS forms for different health settings, referred to as "the third generation of assessment," has produced the first scientific, standardized methodology in the approach to effective geriatric care.     

Activation of Stratification Strategies and Results of the interventions on frail patients of Healthcare Services (ASSEHS) DG Sanco Project No. 2013 12 04

To face the challenge of active and healthy ageing (AHA), European Health Systems and services should move towards proactive, anticipatory and integrated care. Health care systems thus need to personalize services, put patients at the centre of care and provide services using the adequate resources. Population health risk management is emphasized through the use of tools to stratify people with chronic diseases according to their risk. Effective screening of frailty is vital for optimizing the care of frail populations at risk. The Activation of Stratification Strategies and Results of the interventions on frail patients of Healthcare Services (ASSEHS) EU project (N° 2013 12 04) is an international effort whose aim is to bring together stratification-related professionals from Health Services, Academia and Research in the EU in order to (i) study current existing health risk stratification strategies and tools, (ii) spread their use and application on frail elderly patients, (iii) minimize deterioration of conditions and/or (iv) prevent emergency or hospital admissions. The analysis of Risk Stratification in different Health Systems will generate conclusions and risk stratification solutions, which will be transferable to a variety of regions in the future. ASSEHS is in line with Area 4 of the B3 Action Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA).     

Impact of integrated home care services on hospital use

OBJECTIVE: To examine the effect of a home care program based on comprehensive geriatric assessment and case management on hospital use and costs among frail older individuals. DESIGN: Quasi-experimental study with a 6-month follow-up. SETTING: Vittorio Veneto, a town in northern Italy. PARTICIPANTS: One hundred fifteen frail older people who applied for integrated home care services. INTERVENTION: Each patient was assessed with the Minimum Data Set for Home Care, and, subsequently, a case manager and a multidisciplinary team delivered social and health care services as indicated. MAIN OUTCOME MEASURES: We determined the hospital admissions and days spent in the hospital for all subjects during the first 6 months after the implementation of the home care program and compared them with the rate of hospitalization that the same patients had experienced in the 6 months preceding the implementation of the program. RESULTS: After the implementation of the integrated home care program, there was a significant reduction in the number of hospitalizations compared with pre-implementation (56% vs 46%, respectively; P < .001), associated with a reduction in the number of hospital days, both at the individual patient level (28+/-23 days vs 18+/-15 days, respectively; P < .01) and for each admission (16+/-12 days vs 12+/-8 days, respectively; P < .01). This resulted in a 29% cost reduction with an estimated savings of $1260 per patient. CONCLUSIONS: The implementation of an integrated home care program based on the use of a comprehensive geriatric assessment instrument guided by a case manager has a significant impact on hospitalization and is cost-effective.     

POLICIES FOR CARERS

Negotiations on the future of the Home and Community Care Program provide an ideal opportunity to implement policies aimed at assisting those caring for frail and confused elderly people. The principal source of community care is, in fact, informal care by families and this article describes the experiences of a group of caring families. It then pro-poses a range of services, benefits and other means of alleviating some problems of home-based care. It is emphasised that the reorganisation of community care services under HACC must recognise carers' needs.     

Managed long-term care: care integration through care coordination

The New York State managed long-term care demonstration program combines traditional home, community, and institutional long-term care services with other benefits integral to maximizing overall well-being for a frail elderly population. A distinguishing feature of the model is the responsibility to coordinate both covered and noncovered services. This article, a case study of VNS CHOICE, a managed long-term care plan that serves 2,500 New York City residents, describes the program's operating structure, service delivery model, and care management strategies. By providing a capitated Medicaid long-term care benefit, VNS CHOICE can utilize a broad array of services, offer significant flexibility to care management staff, and support member and family involvement in care planning. Its broad care coordination responsibility allows it to achieve integrated care without integrated financing.     

Co-Learning With Home Care Aides and Their Clients: Collaboratively Increasing Individual and Organizational Capacities

Changes in health care provide unprecedented opportunities for collaboration across research, education, and practice for the common goal of enhancing the well-being of older adults and their caregivers. This article describes how a pilot project, Promoting Seniors’ Health with Home Care Aides, has synergistic education, research, and practice effects that enhance individual and organizational capacities. This pilot is an innovative partnership with home care aides to deliver a safe physical activity program appropriate for frail seniors in a real-life public home care program. The intervention and research occur in older adults’ homes and thus provide rare opportunities for the research team and partners to learn from each other about dynamics of home care in older adults’ life contexts. Co-learning is essential for continuous quality improvement in education, research and practice. The authors propose to establish “teaching home care” to ensure ongoing co-learning in gerontology and geriatrics.     

The changing balance of government and family in care for the elderly in Sweden and other European countries

Patterns of care for the elderly have changed dramatically in Sweden over the post‐war years, and new trends have emerged in the last decade. Relatively fewer elderly are institutionalised or use public Home Help and more are helped by family members. The family structure of the elderly in Sweden is more favourable today than before for providing help: more elders are married (or cohabit) and stay married longer and more of them have children and other kin than previously. Although old parents and their offspring very seldom live together, they often do not live far apart. Social services increasingly target elders who are short on kin, very frail and live alone, a pattern that is common in European countries. Both carers and cared‐for elderly persons want shared responsibility, that state and family together provide for frail elders. Paradoxically, more elders are cared for longer and more by their families, but eventually also a larger proportion of elders than before use public services; in particular, more elderly persons now use institutional care for some period before the end of their life than previously. This paper draws on evidence across 50 years of shifting patterns in Swedish old age care and makes comparisons with living arrangements and patterns of care in several western European countries. ‘Cast me not off in the time of old age; forsake me not when my strength faileth’.

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Cost-effectiveness of home care.

Home health care is uniformly accepted by patients, caregivers, health professionals, policymakers, and the public as a desirable way to provide care to disabled individuals and the frail elderly. Given the lack of positive impact of home care upon functional status, cost, and nursing home use, as well as documented additional cost, future research must focus upon positive aspects from past experiences. Careful targeting of patients most likely to benefit from this care has produced better results. Satisfaction with care has been shown consistently. Managed home health care may have the potential, especially the impact of physician involvement with team care on hospital use, to contain costs. The intuitive belief that home care is beneficial and a worthwhile expense, held by policymakers and health care professionals alike, needs to be fully researched by studies that carefully examine the wide spectrum of home care benefits for disabled or chronically ill individuals in relation to varying cost levels that the population and health care system can absorb. The challenge is here, and those who believe in home care need to make use of the results of these previous, rather nonsupportive studies. Additional research is needed to measure the impact of active physician participation in the team care provision of home care services and the impact of managed home care on the cost of hospital care in the population most at risk for recurrent hospitalization. This same research must document not only more effective targeting of individuals, but also the maintenance of increased satisfaction with care--strongest motive for the need to prove the cost-effectiveness of home care.     

Home visits in a rural office practice

Objective:To describe the clinical features of home visits and their role in continuity of care, costs, and benefits in a rural office practice. Design:Prospective study of all home visits performed during a 26-month period. Setting:A general medicine teaching office practice located in rural Virginia. Patients:All persons to whom home visits were made during the study period. Main results:138 home visits were made to 47 patients who had a mean age of 73.2 years. Home visits accounted for 1.4% of patient encounters in the practice, required a mean of 7.1 miles of one-way travel and a mean of 48 minutes, including travel time, to complete, and generated $36 in income per visit. Most patients (27 of 47) were not permanently homebound. Reasons for patients’ being homebound were grouped into six categories (acute illness, frail elderly, terminal illness, advanced chronic disease, neurologic problem, and miscellaneous reasons). The reasons for visits were grouped into four categories (acute self-limited illness, exacerbation of chronic disease, routine follow-up of chronic disease, and psychosocial problem). Physicians judged that 80% of home visits represented appropriate use of their services. In addition, 46% of home visits made an emergency room visit unnecessary, and 9% made a hospital admission unnecessary. At the time of 75% of home visits, physicians reported personal benefits of making the visit. Conclusions:Home visits have an important role in the care of ambulatory as well as permanently homebound patients. While physicians judged most home visits to be appropriate and personally beneficial, these visits required more time and generated less revenue than did office visits for comparable problems. Because home visits generated as well as prevented the use of medical services, their impact on the overall cost of medical care in this setting is unclear. Received from the Division of General Medicine, Department of Medicine, University of Virginia Health Sciences Center, Charlottesville, Virginia.     

Emotional support from family members and subjective health in caregivers of the frail elderly at home in Japan

This study sought to determine the factors associated with subjective health in caregivers of the frail elderly living at home, using multivariate regression analysis. Data were collected from 130 caregivers of frail elderly persons listed on a roster for utilization of day service or short stay service from two Home Visit Nursing Care Stations, using self-administered questionnaire from January to February of 2005. Family caregivers were defined as co-residents family members who provided a minimum of 1 h of daily care for at least 3 months. Multiple logistic regression analysis was performed to examine the factors associated with subjective health in caregivers of the frail elderly at home. Subjects with good health had less depressive symptom (p=0.001), much emotional support (p=0.003) and low caregiver burden (p=0.03). Multivariate logistic regression analysis showed good health had a significantly positive association with only much emotional support after adjustment for confounders. Of the total effect of emotional support on subjective health, the direct effect (84.7%) was much greater than the indirect effect (15.3%). Results indicate that much emotional support from family member for caregiver is essential for better subjective health in caregivers.     

Bringing managed care home to people with chronic,disabling conditions: prospects and challenges for policy,practice, and research

This article examines the challenges and opportunities inherent in the idea that home care organizations may be able to reinvent themselves into managed care systems for the frail elderly and chronically ill. Data come from three sources: (a) existing literature, (b) a survey with experts, and (c) insights from an organization with direct experience in designing and implementing first- and second-generation managed care programs. The authors conclude that although even the best-positioned home care organizations will face significant challenges in transitioning to managed care systems (e.g., establishing medical linkages, building managed care capacity, securing funding, dealing with regulatory hurdles), changes in the environment may enable these challenges to be overcome. Home care organizations are beginning to use innovative techniques to manage care, and those with a strong commitment to the chronically ill may be interested and capable of pursuing the option of becoming home-based managed chronic care programs.     

The Medicare Prospective Payment System and the care of the frail elderly

The development of the Medicare Prospective Payment System based on diagnosis-relating groupings is reviewed. Special emphasis is placed on analysis of the provisions that have a potential impact on geriatric medicine and on the care of the frail elderly. The authors conclude that in its present form, the DRG system may systematically undercompensate hospitals for treating the frail elderly and, therefore, result in attempts by some hospitals to reduce or avoid altogether programs in geriatric medicine and admissions of frail elderly persons. These effects, together with federal and state efforts to limit nursing home and home care costs, may result in a major under-provision of care for the frail elderly and exclusion of clinical geriatric medicine from the medical care system.     

Pain management in frail, community-living elderly patients.

BACKGROUND: Pain is a common problem among older people living in different community settings. As indicated by the World Health Organization (WHO), pain can be relieved using pharmacologic agents. However, pain continues to be addressed inadequately. OBJECTIVES: To describe the prevalence of pain in frail elderly people living in the community and to evaluate the adequacy of pain management. METHODS: We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home health care programs. Twelve home health care agencies participated in the project evaluating the implementation of the Minimum Data Set for Home Care instrument. We enrolled 3046 patients, 65 years and older, in the present study. The main outcome measures were the prevalence of daily pain and analgesic treatment. RESULTS: A total of 1341 individuals (39%, 49%, and 41% of those aged 65-74, 75-84, and > or = 85 years, respectively) reported daily pain. Of patients with daily pain, 25% received a WHO level 1 drug; 6%, a WHO level 2 drug; and 3%, a WHO level 3 drug (eg, morphine sulfate). Patients 85 years or older were less likely to receive analgesics compared with the younger patients (univariate odds ratio, 0.73; 95% confidence interval [CI], 0.60-0.89). Another independent predictor of failing to receive any analgesic was low cognitive performance (adjusted odds ratio, 0.80; 95% CI, 0.69-0.93). CONCLUSIONS: Daily pain is prevalent among frail elderly patients living in the community and is often untreated, particularly among older and demented patients.     

A patient-completed screening instrument for functional disability in the elderly

PURPOSE: Although multi-disciplinary geriatric assessment of elderly patients has been shown to be effective in identifying new diagnoses and previously unknown disabilities and in decreasing hospitalization and mortality, time and financial constraints prevent most internists and office practitioners from using this approach with their older patients. Several instruments to screen older persons for functional disability have been proposed, but there are limited data regarding their utility or effectiveness in clinical medicine. This study developed a short, patient-completed screening assessment instrument (the Functional Assessment Screen), compared it to a standard, multi-disciplinary geriatric evaluation, and determined the screening instrument's ability to predict future use of home care services in a group of elderly patients. PATIENTS AND METHODS: The screening instrument was piloted retrospectively using data from patients seen in the previous 2 years at a hospital-based geriatrics clinic in Wisconsin. Using these results, a revised instrument was developed and mailed to 80 consecutive new patients who presented to the clinic for multi-disciplinary geriatric assessment and primary care. These patients were interviewed 18 months later to determine use of home services, institutionalization, and death after the initial visit. RESULTS: Fifty-eight of 80 eligible patients (72%) completed both the clinic evaluation and 18-month follow-up. The patients were an elderly (mean age of 76), frail (average of three medical diagnoses), functionally disabled group (dependent in an average of 3.7 instrumental activities of daily living and 2.7 activities of daily living). Nine of the 58 enrolled patients (15%) were institutionalized, five (9%) died, and 31 (53%) required new home services after 18 months. The screening variables were sensitive but less specific than clinic providers' judgment in identifying abnormalities in social, economic, or physical health status. The relative risk of eventual home service use was elevated in patients reporting poor health status (relative risk of 3.5, 95% confidence interval [CI] 9.9 to 1.2), and dependency in housework (relative risk of 3.0, 95% CI 5.1 to 1.7), shopping (relative risk of 2.6, 95% CI 4.7 to 1.5), meals (relative risk of 2.4, 95% CI 3.4 to 1.7), dressing (relative risk of 2.2, 95% CI 3.0 to 1.6), or bathing (relative risk of 2.2, 95% CI 3.2 to 1.5). Home services were used in 16% of patients with no positive responses to a subset of four of the screening questions; usage rose to 22% with one positive response, and to 89% (relative risk of 4.5, 95% CI 9.2 to 2.1) with two or more positive responses. CONCLUSIONS: This screening instrument identified a group of elderly patients at much higher risk for increased home service use than other patients in a geriatrics clinic. If validated in other populations, such an instrument may identify frail, elderly patients in office practice at high risk for use of home services. These patients could be targeted for more complete multi-disciplinary geriatric assessment to identify and treat disease and disability responsible for increased service use and declining health.