Abstract

INTRODUCTION

In recent years, the ageing population has led to discussion of the needs and particularities of older adults as heath care system users. There is intense concern to maintain health care quality and sustainability with regards costs.⁴4 . Bielaszka-DuVernay C. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-4. DOI:10.1377/hlthaff.2011.0043 ^{, 12}12 . Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-33. DOI:10.1001/jama.298.22.2623 ^{, 25}25 . Lourenço RA, Martins CSF, Sanchez MAS, Veras RP. Assistência ambulatorial geriátrica: hierarquização da demanda. Rev Saude Publica. 2005;39(2):311-8. DOI:10.1590/S0034-89102005000200025 ^{, 38}38 . Wagner JT, Bachmann LM, Boult C, Harari D, Rentein-Kruse W, Egger M, et al. Predicting the risk of hospital admission in older persons: validation of a brief self-administered questionnaire in three European countries. J Am Geriatr Soc. 2006;54(8):1271-6. DOI:10.1111/j.1532-5415.2006.00829.x

Trust and bonding are values inherent to qualified health care.²²22 . Leff B, Reider L, Frick KD, Scharfstein DO, Boyd CM, Frey K, et al. Guided care and the cost of complex healthcare: a preliminary report. Am J Manag Care. 2009;15(8):555-9. ^{, 27}27 . Malta DC, Cecílio LCO, Merhy EE, Franco TB, Jorge AO, Costa MA. Perspectivas da regulação na saúde suplementar diante dos modelos assistenciais. Cienc Saude Coletiva. 2004;9(2):433-44. DOI:10.1590/S1413-81232004000200019 To guarantee the continuance of these values, a care pathway needs to be established within the system.²⁵25 . Lourenço RA, Martins CSF, Sanchez MAS, Veras RP. Assistência ambulatorial geriátrica: hierarquização da demanda. Rev Saude Publica. 2005;39(2):311-8. DOI:10.1590/S0034-89102005000200025

The older people have specific needs due to clinical-functional and socio-familial characteristics peculiar to this group. Care models for this segment of the population need to be centered on the individual, considering such characteristics. In order to do this, attention should be organized in an integrated way and care needs to be coordinated following network logic throughout the care pathway.

However, as a result of fragmentation in care, current health care service provision consists of a multiplicity of appointments, tests and other procedures which, in addition to increasing costs, do not guarantee a positive cost-effectiveness relationship.²⁸28 . Malta DC, Merhy EE. O percurso da linha do cuidado sob a perspectiva das doenças crônicas não transmissíveis. Interface (Botucatu). 2010;14(34):593-606. DOI:10.1590/S1414-32832010005000010 ^{, 36}36 . Veras R. Em busca de uma assistência adequada à saúde do idoso: revisão da literatura e aplicação de um instrumento de detecção precoce e de previsibilidade de agravos. Cad Saude Publica. 2003;19(3):705-15. DOI:10.1590/S0102-311X2003000300003 ^{, 37}37 . Veras RP. Gerenciamento de doença crônica: equívoco para o grupo etário dos idosos. Rev Saude Publica. 2012;46(6):929-34. DOI:10.1590/S0034-89102012000600001 Health care is not providing a secure service to older adults and their families. As a consequence, health care systems are overloaded, implying higher costs and inefficiency.³⁶36 . Veras R. Em busca de uma assistência adequada à saúde do idoso: revisão da literatura e aplicação de um instrumento de detecção precoce e de previsibilidade de agravos. Cad Saude Publica. 2003;19(3):705-15. DOI:10.1590/S0102-311X2003000300003

In an attempt to deal with this problem, in North America and Europe in recent years health care service provision has been offered in a coordinated and integrated way by Integrated Services Delivery (ISD) programs.²⁴24 . Leutz WN. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q. 1999;77(1):77-110, iv-v. DOI:10.1111/1468-0009.00125 These programs are developed to improve continuity in health care and to increase the efficiency of health care services, especially those provided to older adults and those with disabilities.

The aim of this study was to conduct a detailed review of the literature on models evaluating the effectiveness of integrated and coordinated health care models for older adults.

METHODOLOGICAL PROCEEDINGS

A review was conducted of health care models for older adults, the effectiveness of which had been evaluated. The following bibliographical databases were consulted to identify studies: PubMed, through the National Center for Biotechnology Information (NCBI); The Cochrane Library; Lilacs; PAHO; WOLIS MEDCARIBE and IBECS through the Virtual Health Library (BVS); Web of Science; Scopus and SciELO.

The descriptors used to search the databases were: Delivery of Health Care, Effectiveness, Program Evaluation, Health Care, Structure of Services, Aged, Elderly, Older, Health Services for the Aged, Old Age Assistance, Outcome and Process Assessment, Quality Integrated Care, Demonstration Programs, Balance of Care, Aged, 80 and over, Quality of Health Care.

These descriptors were combined in a variety of ways to find the greatest possible number of publications in the databases. The combinations followed the order: intervention, population and outcome.

No limits were placed on the dates of publication. Texts available in English, Spanish or Portuguese were selected and, at this stage, there was no restriction placed on the type of study.

At each stage of the selection process, the studies were selected by pairs of authors (RCS, RTSVR, LMAMS and ACLCG). The studies had to refer to assistance programs and integrated health care for older adults and evaluate effectiveness. Older adults were deemed to be those aged ≥ 60.

In total, 5,135 titles were identified. After eliminating duplicates and reading abstracts, thirty publication were selected. A further three articles found in the references of the selected articles were added to complement information.

After reading and analyzing the 33 articles, 12 works referring to five coordinated and integrated health care models for older adults were included. These studies evaluated the effectiveness of the models with significant results regarding the integration of health care services. Works describing models without analyzing results, those which did not present the data analyzed or did not demonstrate methodological rigor were excluded.

Pairs of authors read the entire articles, using a third reviewer in case of discrepancies in the eligibility criteria. A summary of the data was added to a pre-formulated and standardized record, from which the researchers extracted the following data for each eligible study: type and aim of the study, population, description of the intervention, location, year implemented and duration and financing of the model, result of evaluation of costs, reductions in number of hospitalizations, impact analysis, user satisfaction or other evaluation. Space was included for a subjective evaluation of the quality of the study and for researchers’ comments, for example, on research bias or strong points.

RESULTS

The results of the research included the best information on integrated systems presented in the literature. The principle characteristics of the five models of coordinated and integrated health care for older adults according to structural composition, assistance process and results¹⁴14 . Donabedian A. Evaluating the quality of medical care [1966 reprint]. Milbank Q. 2005;83(4):691-729. DOI:10.1111/j.1468-0009.2005.00397.x are shown in the table.

The Integrated Care System for Older Adults (SIPA) is a Canadian program providing integrated care for frail older adults.¹1 . Béland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(4):367-73. ^{, 2}2 . Béland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006;25(1):5-42. The structure of this program contains both institutional and community services. It includes delivering care plans and monitoring by a case manager.¹1 . Béland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(4):367-73. ^{, 2}2 . Béland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006;25(1):5-42.

The institution based services offered are: hospital ER, short and long term hospitalizations, hospitalizations for rehabilitation, institutionalization and palliative care. Community based services were: medical prescriptions, general and specialty clinical appointments, in-home assistance, adapted housing for older individuals with some dependence, in-home technical support, “hospital dia” (Day Hospital) and day centers.¹1 . Béland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(4):367-73. ^{, 2}2 . Béland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006;25(1):5-42.

Triage was performed to identify frailty, confirmed by functional assessment (IsoSMAF score ≤ 10)¹1 . Béland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(4):367-73. ^{, 2}2 . Béland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006;25(1):5-42. for individuals to qualify for the program. Each team is responsible for 160 patients. The family GP received an annual $400 Canadian dollars subsidy per patient to compensate for the time spent communicating with other team members. The teams were composed of a case manager (nurse or social worker), community nurses, social workers, occupational therapists, in-home assistants, GP, pharmacist (one per area) and community resource organizers (one per area).¹1 . Béland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(4):367-73. ^{, 2}2 . Béland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006;25(1):5-42.

The SIPA model was constructed based on a clinical trial of 1,230 older adults aged ≥ 64. The intervention was analyzed and found to result in a 22.0% reduction in institutional costs and a 50.0% reduction in hospitalizations for acute events, with no difference found in stays in the intermediary care sector. Increased user and carer satisfaction was also found, with no difference in the carer’s workload or in the family’s spending. There was a 44.0% increase in community service spending, although the main impact was freeing up hospital beds previously occupied by patients awaiting institutionalization.

The Program of All-Inclusive Care for the Elderly (PACE)¹⁰10 . Chatterji P, Burstein NR, Kidder D, White A. Evaluation of the Program of All- Inclusive Care for the Elderly (PACE) demonstration: the impact of PACE on participant outcomes. Cambridge (MA): Abt Associates; 1998. [citado 2014 fev 26] p.1-60. Disponível em: http://www.npaonline.org/website/download.asp?id=
http://www.npaonline.org/website/downloa... originated in On-Lok in Chinatow, USA, and offers health care to individuals with disabilities and frail older adults on low income and eligible for in-home nursing care. The network is structurally limited and offers medical and social services, supported by an inter-disciplinary team, as well as a day center for adults (social center, centralizing medical and social services and, in many cases, residence for patients). The team’s intense effort in monitoring and managing cases resulted in reduced institutionalization, reduced use of ER services and reduced hospitalization times.¹⁰10 . Chatterji P, Burstein NR, Kidder D, White A. Evaluation of the Program of All- Inclusive Care for the Elderly (PACE) demonstration: the impact of PACE on participant outcomes. Cambridge (MA): Abt Associates; 1998. [citado 2014 fev 26] p.1-60. Disponível em: http://www.npaonline.org/website/download.asp?id=
http://www.npaonline.org/website/downloa... ^{, 32}32 . White AJ. Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) demonstration: the effect of PACE on costs to medicare: a comparison of medicare capitation rates to projected costs in the absence of PACE: final report. Cambridge (MA): Abt Associates; 1998 [citado 2014 fev 24]. p.1-33. Disponível em: www.abtassociates.com/reports/19986221706191.pdf
www.abtassociates.com/reports/1998622170...

A study carried out between 1995 and 1997¹⁰10 . Chatterji P, Burstein NR, Kidder D, White A. Evaluation of the Program of All- Inclusive Care for the Elderly (PACE) demonstration: the impact of PACE on participant outcomes. Cambridge (MA): Abt Associates; 1998. [citado 2014 fev 26] p.1-60. Disponível em: http://www.npaonline.org/website/download.asp?id=
http://www.npaonline.org/website/downloa... analyzed PACE outcomes. The authors suggested that use of outpatient services maintained “improved” health, avoiding higher costs in other areas of care. The high level of outpatient care use (93.0% in the first six months of monitoring) found in the study may be the result of a lack of access to medical care before entering the PACE, as users were minority groups, individuals living in extreme poverty and with low levels of schooling.

Another study³²32 . White AJ. Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) demonstration: the effect of PACE on costs to medicare: a comparison of medicare capitation rates to projected costs in the absence of PACE: final report. Cambridge (MA): Abt Associates; 1998 [citado 2014 fev 24]. p.1-33. Disponível em: www.abtassociates.com/reports/19986221706191.pdf
www.abtassociates.com/reports/1998622170... evaluating PACE outcomes was published in 1998. Its results estimated savings for the financer (Medicare) to be 38.0% in the first six months and 16.0% between the seventh and 12^th months of the period of the study. There was greater use of outpatient services, less use of hospital services, less time in nursing homes and more time spent in the community. More patients reported better perceived health, quality of life, satisfaction with health care and better perception of their functional state compared with the control group.³²32 . White AJ. Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) demonstration: the effect of PACE on costs to medicare: a comparison of medicare capitation rates to projected costs in the absence of PACE: final report. Cambridge (MA): Abt Associates; 1998 [citado 2014 fev 24]. p.1-33. Disponível em: www.abtassociates.com/reports/19986221706191.pdf
www.abtassociates.com/reports/1998622170...

The Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA),¹1 . Béland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos AP, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(4):367-73. ⁹9 . Burton LC, Weiner JP, Stevens GD, Kasper J. Health outcomes and medicaid costs for frail older individuals: a case study of a MCO versus fee-for-service care. J Am Geriatr Soc. 2002;50(2):382-8. DOI:10.1046/j.1532-5415.2002.50074.x another Canadian program, formulated its structure in partnership with local health care and community services. There were six components to its functioning: coordination between regional and local decision makers, one single entry point, individual evaluation instruments (triage of frailty risk using the PRISMA-7, confirmed by the FAMS (Functional Autonomy Measurement System) functional evaluation system, together with management systems for complex cases, case management, individualized care plans and computerized medical records.

The PRISMA¹⁹19 .Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):10718. DOI:10.1093/geronb/gbp027 institutional services included in-home care, rehabilitation services, hospital services, day center, voluntary services (personal care, home maintenance, delivering meals, community transport and voluntary care) and social services. The main focus of the program, coordination, is established at each level of the organization.

In a study conducted during the first four years of PRISMA¹⁹19 .Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):10718. DOI:10.1093/geronb/gbp027 in three regions Quebec, 920 older adults aged ≥ 75 or 77 and identified as at risk of frailty were monitored. Greater use was made of the ER, although this was generally not followed by hospitalization, which suggests inappropriate use of these services. Even so, hospital admissions were a little higher than in the control group in the first year, although this situation was reversed in the fourth year, as expected.

The small difference in results of evaluations of the impact of PRISMA¹⁹19 .Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):10718. DOI:10.1093/geronb/gbp027 compared with the control group may be due to the local health care system being integrated to ISD templates.

The study found a 13.9% increase in patient and carer satisfaction with the health care received. The workload was similar at the end of the four years, when the individuals monitored had grown older and had greater functional loss.¹⁹19 .Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):10718. DOI:10.1093/geronb/gbp027

Even with greater user dependence, the probability of using the ER was lower in the fourth year [0.49 (Prisma group) versus 0.54 (control group), p < 0.001].¹⁹19 .Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):10718. DOI:10.1093/geronb/gbp027

The Guided Care²2 . Béland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006;25(1):5-42. Program is a system of health care service provision, offered in several American states, focusing on primary health care and an in-home approach. Although the health care service provider facilities are not linked to the Program, they are available in the community and the Program coordinates their use by patients.

The primary health care services are offered by a team composed of a trained nurse, a GP and a multi-disciplinary team. The Program provides medical records available on line, comprehensive geriatric evaluation, evidence based care plans, case management (nurse), transitional care, self-management and support to the carer.⁵5 . Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2001;171(5):460-6. DOI:10.1001/archinternmed.2010.540

6 . Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, et al. Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2008;63(3):321-7. ^{- 7}7 . Boyd CM, Reider L, Frey K, Scharfstein D, Leff B, Wolff J, Groves C, et al. The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial. J Gen Intern Med. 2010;25(3):235-42. DOI:10.1007/s11606-009-1192-5 ^{, 22}22 . Leff B, Reider L, Frick KD, Scharfstein DO, Boyd CM, Frey K, et al. Guided care and the cost of complex healthcare: a preliminary report. Am J Manag Care. 2009;15(8):555-9. ^{, 31}31 . Marsteller JA, Hsu YJ, Reider L, Frey K, Wolff J, Boyd C, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010;8(4):308-15. DOI:10.1370/afm.1134

Nursing services are performed by professionals specially trained to monitor the patient⁶6 . Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, et al. Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2008;63(3):321-7. and their activities are divided into eight processes: (1) conducting a comprehensive geriatric evaluation of the patient in their own home, (2) drawing up a care plan, (3) monthly monitoring of patients, (4) monitoring patient’s transition between care provision, smoothing transfers, (5) making coordinated efforts to ensure all patients receive care, (6) encouraging self-management, (7) providing guidance and support to the family carer and (8) facilitating appropriate access to community resources.⁵5 . Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2001;171(5):460-6. DOI:10.1001/archinternmed.2010.540

A clinical trial⁵5 . Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2001;171(5):460-6. DOI:10.1001/archinternmed.2010.540 involving care teams and 904 older adults aged ≥ 65, identified as at high risk of hospitalization was conducted by Boult et al in 2001. This study yielded several complementary publications and their principle results suggest a 29.7% reduction in in-home service use, a small percentage reduction in hospital use (26.0% versus 30.0%), nursing homes (20.0% versus 22.0%), and specialist nursing services (8.0% versus 9.0%), compared with the control group. They also reported less spending by the families, less functional loss, better perceived health and greater patient satisfaction with the model.⁵5 . Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2001;171(5):460-6. DOI:10.1001/archinternmed.2010.540

6 . Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, et al. Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2008;63(3):321-7. ^{- 7}7 . Boyd CM, Reider L, Frey K, Scharfstein D, Leff B, Wolff J, Groves C, et al. The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial. J Gen Intern Med. 2010;25(3):235-42. DOI:10.1007/s11606-009-1192-5 ^{, 23}23 . Leung AC, Liu C, Chow NW, Chi I. Cost-benefit analysis of a case management project for the community-dwelling frail elderly in Hong Kong. J Appl Gerontol. 2004;23(1):70-85. DOI:10.1177/0733464804263088 ^{, 31}31 . Marsteller JA, Hsu YJ, Reider L, Frey K, Wolff J, Boyd C, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010;8(4):308-15. DOI:10.1370/afm.1134

The professionals involved (such as doctors and nurses) were also satisfied, there was improved doctor-patient communication with chronic patients and their respective families and better knowledge of their clinical conditions on the part of the patients.³¹31 . Marsteller JA, Hsu YJ, Reider L, Frey K, Wolff J, Boyd C, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010;8(4):308-15. DOI:10.1370/afm.1134

The analyses of the studies of the Guided Care²²22 . Leff B, Reider L, Frick KD, Scharfstein DO, Boyd CM, Frey K, et al. Guided care and the cost of complex healthcare: a preliminary report. Am J Manag Care. 2009;15(8):555-9. Program suggests reduced hospital use, ER use, rehabilitation use and qualified installation of nursing and in-home health care services use. The avoided costs of these services appear to be more than sufficient to compensate for the costs of providing this primary care program. There was also improved self-reported health care, especially among those patients with multiple chronic diseases.⁷7 . Boyd CM, Reider L, Frey K, Scharfstein D, Leff B, Wolff J, Groves C, et al. The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial. J Gen Intern Med. 2010;25(3):235-42. DOI:10.1007/s11606-009-1192-5

The Geriatric Resources for Assessment and Care of Elders (GRACE) is a local health care service program for older adults on low income in the USA.¹²12 . Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-33. DOI:10.1001/jama.298.22.2623 ^{, 13}13 . Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-6. DOI:10.1111/j.1532-5415.2009.02383.x The institutions used by the patients are not linked to the Program, but there is a commitment not to lose patient data. The computerized medical record “accompanies” the patient in all procedures, as it can be accessed via the internet. This enables all professionals, from GRACE or otherwise, to register their activities, creating an integrated network.¹³13 . Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-6. DOI:10.1111/j.1532-5415.2009.02383.x

Based on tracking the risk of hospitalization using the PRA (instrument to predict risk of repeated hospital admission), the older adult is monitored by the support team, in collaboration with the primary care doctor and an inter-disciplinary geriatric care team. This team is managed by a geriatric specialist who interacts with community health care services. ACOVE^aa A set of indicators of quality developed sepcifically for older adults, aiming to identify the quality of health care provided to the most vulnerable older adults, with the highest chance of dying or becoming seriousl incapacitated in the next two years. (Assessing Care of Vulnerable Elder) recommendations are used as indicators of care quality and medical records accessed through the internet integrate the patient with local health care services.¹³13 . Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-6. DOI:10.1111/j.1532-5415.2009.02383.x

The support team conduct a comprehensive, annual geriatric assessment and the inter-disciplinary geriatric care team develop an individualized care plan, applying protocols of care specific to geriatric alterations. The inter-disciplinary team meet weekly to review implemented care plans.¹³13 . Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-6. DOI:10.1111/j.1532-5415.2009.02383.x

A clinical trial involving 951 older adults aged ≥ 65 was conducted between 2002 and 2004. Support provided to the primary care doctor during the monitoring period was geriatric assessment of the patient, the multi-specialty center, the unit for appointments and admitting acute cases, specialized nursing services and the physician house call program.¹²12 . Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-33. DOI:10.1001/jama.298.22.2623

The estimated results suggest less use of ER not followed by hospitalization [1,445 (n = 474) versus 1,748 (n = 477)], and the estimates for visits to the ER, hospital admission and hospital dia were lower among patients identified as being at higher risk of hospitalization (PRA > 0.4) in the second year of the study. There was no significant difference in hospital admissions or outpatient visits, nor in readmission within 30 days of the first discharge.¹²12 . Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-33. DOI:10.1001/jama.298.22.2623

Close collaboration between primary care and doctors working in the hospitals encouraged better use of limited resources in geriatrics and the specially trained inter-disciplinary geriatrics team had more impact on the patient’s results.¹²12 . Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-33. DOI:10.1001/jama.298.22.2623

Although the results of the GRACE¹³13 . Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-6. DOI:10.1111/j.1532-5415.2009.02383.x evaluation indicated greater costs in the low risk group, a cost-effectiveness analysis is needed to quantify the benefits in quality adjusted life years, rather than in dollars. This would help to guide clinical decisions for this population.

The ISD model was implemented in Bois-Francs, Canada, in 1997. The model integrated the geronto-geriatric services available in the location and coordinated promotion and prevention of diagnosis, treatment, rehabilitation, long-term care and palliative care. Patients were admitted to the service after a comprehensive geronto geriatric assessment. The data were made available on an electronic medical record accessible to all local health care services, including by professionals who supported the network.³⁵35 . Tourigny A, Durand PJ, Bonin L, Hébert R, Rochette L. Quasi-experimental study of the effectiveness of an integrated service delivery network for the frail elderly. Can J Aging. 2004;23(3):229-43. DOI:10.1353/cja.2004.0038

An evaluative study was conducted during the program’s implementation and compared outcomes with those of a control group in the Drummond-ville area, where no ISD network was established. This study, of a quasi-experimental design, monitored 482 individuals for three years. The results do not show less use of hospital or emergency services compared with the control groups, although less use was made of local community services. However, carers had a lower workload and there was less desire to move into an institution.³⁷37 . Veras RP. Gerenciamento de doença crônica: equívoco para o grupo etário dos idosos. Rev Saude Publica. 2012;46(6):929-34. DOI:10.1590/S0034-89102012000600001

The importance of the care process associated with the structure can be observed in the experience of Rovereto, a city in Italy with a wide range of health care services geared towards the older people, although not integrated. Integrating local services after adding a case manager, care plan and geriatric assessment to a community unit resulted in reduced risk of hospitalization and shorter stays when this was the case, and reduced functional and cognitive decline. Consequently, total per capita health care costs were reduced.³3 . Bernabei R, Landi F, Gambassi G, Sgadari A, Zuccala G, Mor V, et al. Randomised trial of impact of model of integrated care and case management for older people living in the community. BMJ. 1998;316(7141):1348-51. DOI:10.1136/bmj.316.7141.1348

Some of the selected studies did not report the structuring of the integrated network, but rather a multi-professional approach⁸8 . Brown L, Tucker C, Domokos T. Evaluating the impact of integrated health and social care teams on older people living in the community. Health Soc Care Community. 2003;11(2):85-94. DOI:10.1046/j.1365-2524.2003.00409.x ^{, 9}9 . Burton LC, Weiner JP, Stevens GD, Kasper J. Health outcomes and medicaid costs for frail older individuals: a case study of a MCO versus fee-for-service care. J Am Geriatr Soc. 2002;50(2):382-8. DOI:10.1046/j.1532-5415.2002.50074.x ^{, 26}26 . MacNeil Vroomen JL, Boorsma M, Bosmans JE, Frijters DHM, Nijpels G, Hout HPJ. Is it time for a change? A cost-effectiveness analysis comparing a multidisciplinary integrated care model for residential homes to usual care. PLoS One. 2012;7(5):e37444. DOI:10.1371/journal.pone.0037444 or case management²⁴24 . Leutz WN. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q. 1999;77(1):77-110, iv-v. DOI:10.1111/1468-0009.00125 ^{, 33}33 . Ruikes FG, Meys AR, Wetering G, Akkermans RP, Gaal BG, Zuidema SU, et al. The CareWell-primary care program: design of a cluster controlled trial and process evaluation of a complex intervention targeting community-dwelling frail elderly. BMC Fam Pract. 2012;13:115. DOI:10.1186/1471-2296-13-115 in caring for the health of the older people. Others merely described the models,¹⁸18 . Hébert R. Home care: from adequate funding to integration of services. Healthc Pap. 2009;10(1):58-64. ^{, 21}21 . Ikegami N. Public long-term care insurance in Japan. JAMA. 1997;278(16):1310-4. DOI:10.1001/jama.1997.03550160030017 ^{, 29}29 . Manthorpe J, Clough R, Cornes M, Bright L, Moriarty J, Iliffe S. Four years on: the impact of the National Service Framework for Older People on the experiences, expectations and views of older people. Age Ageing. 2007;36(5):501-7. DOI:10.1093/ageing/afm078 ^{, 35}35 . Tourigny A, Durand PJ, Bonin L, Hébert R, Rochette L. Quasi-experimental study of the effectiveness of an integrated service delivery network for the frail elderly. Can J Aging. 2004;23(3):229-43. DOI:10.1353/cja.2004.0038 ^{, 34}34 . Sawyer M. Measuring the success of the Arkansas Health Care Access Foundation. J Ark Med Soc. 1998;95(7):279-81. ^{, 39}39 . Wilhelmson K, Duner A, Eklund K, Gosman-Hedström G, Blomberg S, Hasson H, et al. Design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people. BMC Geriatr. 2011;11:24. DOI:10.1186/1471-2318-11-24 implementation³⁰30 . Manton KG, Newcomer R, Lowrimore GR, Vertrees JC, Harrington C. Social/health maintenance organization and fee-for-service health outcomes over time. Health Care Financ Rev. 1993;15(2):173-202. ^{, 34}34 . Sawyer M. Measuring the success of the Arkansas Health Care Access Foundation. J Ark Med Soc. 1998;95(7):279-81. or evolution of the initial model,¹⁵15 . Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997;45(2):223-32. ^{, 20}20 . Hirth V, Baskins J, Dever-Bumba M. Program of all-inclusive care (PACE): past, present, and future. J Am Med Dir Assoc. 2009;10(3):155-60. DOI:10.1016/j.jamda.2008.12.002 without analyzing effectiveness. In two articles, the studies suffered from methodological bias³²32 . White AJ. Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) demonstration: the effect of PACE on costs to medicare: a comparison of medicare capitation rates to projected costs in the absence of PACE: final report. Cambridge (MA): Abt Associates; 1998 [citado 2014 fev 24]. p.1-33. Disponível em: www.abtassociates.com/reports/19986221706191.pdf
www.abtassociates.com/reports/1998622170... and changes in the country’s legislation during the period analyzed,¹⁶16 . Fillenbaum GG, Burchett BM, Dan JD, Blazer G. Health service use and outcome: comparison of low charge, integrated, comprehensive services with usual health care. Aging Ment Health. 2007;11(2):226-35. DOI:10.1080/13607860600844556 compromising the reliability of the results. Clauser et al¹¹11 . Clauser SB, Kidder D, Mauser E. “The PACE Evaluation”: two responses. Gerontologist. 1996;36(1):7-8. DOI:10.1093/geront/36.1.7 (1995) outline final considerations regarding the PACE model.

Publications describing the evolution of PACE in the USA report the need to understand the preferences of the populations and to guide families on the approach with the case managers.¹⁵15 . Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997;45(2):223-32. They report difficulties in implementing the model and contracting trained professionals, especially doctors.¹⁵15 . Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997;45(2):223-32. ^{, 20}20 . Hirth V, Baskins J, Dever-Bumba M. Program of all-inclusive care (PACE): past, present, and future. J Am Med Dir Assoc. 2009;10(3):155-60. DOI:10.1016/j.jamda.2008.12.002

FINAL CONSIDERATIONS

The ISD were developed to improve care continuity, increasing the efficiency of the services offered, especially for older adults and those with disability.²⁴24 . Leutz WN. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q. 1999;77(1):77-110, iv-v. DOI:10.1111/1468-0009.00125

Some programs aimed to improve the process of referring and transferring patients between services, e.g., discharge from hospital to in-home care or to a rehabilitation institution.¹⁹19 .Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):10718. DOI:10.1093/geronb/gbp027

Other programs were more ambitious and complex, developing an organization responsible for offering all services to a specific group of individuals. In general, they operated with a budget to hire specialized local services, such as residential homes for the older individuals and hospital services.¹⁷17 . Hébert R, Durand PJ, Dubuc N, Tourigny A. Frail elderly patients: new model for integrated service delivery. Can Fam Physician. 2003;49(8):992-7.

This study includes experiences which analyze the use of more complex programs, understanding that coordinating care and integrating the service network are requisites in creating continuity in care.

The main items found in the structure of the programs are hospital services, ER, day centers centralizing specialist services and social activities, in-home care, telephone switchboard, long-term stay institutions and transport for patients in the network. Computerized medical records, accessible through the internet, integrated the patient to services in the network.

There was one entry point for users to enter the system, accompanied by a triage of risk, be that risk of frailty or risk of repeated hospitalization. This was followed by a comprehensive functional or geriatric assessment to orient the care plan. The case manager was presented as the patient’s “coordinator” in the network of institutional and community services.

The results found by the SIPA, PACE and Guided Care programs, systems which invested in recruiting and training the professionals involved, i.e. those which valued the process of providing services, reinforced the benefits of the ISD model for caring for older adults.

The SIPA and PRISMA systems showed significant network integration and care coordination with the patient. This meant benefits developed which went beyond the costs by satisfying users and carers.

This is an important result as the target population of the majority of programs were frail older adults with high levels of functional dependency and consequent work overload of carers. Even so, the patients showed better perceived health and less functional decline and desire to move into an institution.

Increased spending on community services is expected when investment in primary care is increased, including in-home care, in order to reduce use of hospitals, ER and nursing homes in the long term.²⁵25 . Lourenço RA, Martins CSF, Sanchez MAS, Veras RP. Assistência ambulatorial geriátrica: hierarquização da demanda. Rev Saude Publica. 2005;39(2):311-8. DOI:10.1590/S0034-89102005000200025 The PRISMA¹⁹19 .Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):10718. DOI:10.1093/geronb/gbp027 outcomes reinforce this approach in primary care with investment in the management process in order to make other savings in the long term.

A limitation of this study is the small number of studies evaluating health care provision programs for the older individuals, as well as the poor methodological quality of others which were not included. Another limitation was being limited to key words in the languages included, which may have excluded experiences published in other languages.

The results of this study reinforce the need to modify the approach to health care. Patients’ care needs to be managed from entry into the system until end of life, with services integrated at all levels. This configuration has been shown to be the most advantageous for health care systems, for patients and for their families.

This study, developed in the research line of “developing health care models for Older Adults”,^bb Study developed by the Grupo de Pesquisa sobre Envelhecimento e Saúde, Universidade Aberta da Terceira Idade, Universidade do Estado do Rio de Janeiro, January to December 2013. will form part of another project, furthering the discussion of the adoption of one of the models (or a mixed model) to the Brazilian situation.

The Brazilian model needs to be constructed based on the peculiarities of the country regarding current health care system proposals, considering advances and limitations which can be matched to these international experiences.

References

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History