A P P C A R E F i n a l C o n f e r e n c e B r u s s e l s , 2 3 - - PowerPoint PPT Presentation

A P P C A R E F i n a l C o n f e r e n c e B r u s s e l s , 2 3 r d M a y 2 0 1 9

E l e n a P r o c a c c i n i L o c a l H e a l t h A u t h o r i t y n ° 2 M a r c a T r e v i g i a n a

GENER A L INFOR MATION

• Project name: Appropriate care paths for frail elderly patients: a

comprehensive model – APPCARE

• Programme: 3rd Health Programme ; Call: HP-PJ-2014
• Total Budget: € 1.337.071,00
• EC Funding: € 797.314,00
• Duration: 48 months
• Starting date: 1st July 2015
• Partners: Local Health Authority n°2, Erasmus Medical Center

Rotterdam, Polibienestar Research Institute, Gruppo di Ricerca Geriatrico Brescia

B A C K GR OU N D

B A C K G R O U N D

Ageing problems are a common challenge for Europe and health systems: there is a higher frail population in need of long term care, with chronic conditions requiring complex response from a wide range of health professionals, often characterized by fragmented and not appropriated care.

• The importance of avoiding unnecessary hospitalization
• The importance of integrated care
• The importance of prevention

B A C K G R O U N D

THE IMPORTANCE OF AVOIDING UNNECESSARY HOSPITALIZATION

• Elderly people access to ER more frequently;
• They stay longer to ER and their access usually ends into ordinary

admission, with an increasing risks of hospital-related adverse

• utcomes.

B A C K G R O U N D

The importance of integration between health and social care. Even when patients respond to treatment there is a transitional phase immediately after hospital, commonly manifesting as readmission. The risk for readmission arises also from:

• The lack of continuity of care
• The lack of social care

B A C K G R O U N D

The importance of preventive care.

• 1. Being proactive when the first signals of frailty are detected is
• ne of the success key in keeping elderly people healthy.
• 2. Adequate treatment of complex patients and avoid the

insurgence of other comorbidity.

OB J E C TI VES

O B J E C T I V E

Slow the functional status loss in accordance to the patients’ clinical trajectory, thanks to a Comprehensive Geriatric Assessment and an optimization of the connection between hospital, territorial and social care.

O B J E C T I V E

APPCARE SPECIFIC OBJECTIVES

New model for the management of frail elderly people including:

• Standardized application of CGA
• Homogeneous and coordinated care pathway, traced by the geriatrician and

performed through a care management program;

• Particular hospital admission care for +75 pz, with a short intensive observation

period;

• Close link between hospital and territorial care for follow up activities;
• Frailty prevention program (primary and secondary)

A P P C AR E M OD E L

A P P C A R E C O R E W P s

WP4

• Analysis of contexts
• Analysis of best practices

WP5

• Issue of APPCARE model general requirements
• Context adaption of the model

WP7-8-9

• Enrollment and follow up of 3.000 patients

according to the APPCARE model

• Collection of data on the project Database

WP 10 IMPACT ASSESSMENT

B A C K G R O U N D

The results and recommendations of WP4 analysis

• The lack of a standardized and appropriate assessment of the status of the

elderly patients when admitted to hospital, with particular regard to comorbidity.

• Poor, fragmented follow up of patients;
• The lack of clear communication among different specialists/healthcare

providers treating the same patients for different problems;

• The absence of links between prevention and hospital/territorial settings;
• The lack of financial resources to perform prevention and patients

perceving it as not useful

G E N E R A L R E Q U I R E M E N T S

APPCARE MODEL for HOSPITAL CARE

Inclusion criteria: Patients +75 years old coming from emergency room (E.R.) or admittance area. The APPCARE MODEL for the hospital care must include:

• Standardized application of the Comprehensive Geriatric Assessment;
• Assessment of the social and environmental context of the patient ;
• 48h intensive care (short term observation period).

G E N E R A L R E Q U I R E M E N T S

APPCARE MODEL FOR CONTINUITY OF CARE

The APPCARE MODEL for the continuity of care include the following measures:

• Benchmark analysis of already existing clinical protocols for the management of chronic

patients:

• Coordination protocol for follow up for each type of discharge
• Establishment of a case management program for complex patients (homecare

assisted).

• Geriatric follow up of clinical conditions at 1 month and 3 months
• Standardized application of clinical pathways for the most common chronic conditions

(CVD, COPD, …), in accordance with all involved specialists and the benchmark analysis results.

G E N E R A L R E Q U I R E M E N T S

APPCARE MODEL FOR PREVENTIVE CARE

• Benchmark analysis of already existing prevention initiatives and pathways.
• Assessment of risk of fall and polypharmacy.
• Proposal of specific agreed pathways for fall prevention and management of

polypharmacy to at-risk patients

• Monitoring of pathways adherence of enrolled patients.

A P P C A R E A S S E S S M E N T

APPCARE MODEL ASSESSMENT TOOLS

VARIABLE INSTRUMENTS Co-morbidity CIRS Dementia SPMSQ Pre-morbid conditions BARTHEL INDEX Functional Status BARTHEL INDEX Pressure ulcer BRADEN Discharge planning BRASS INDEX VARIABLE INSTRUMENTS Physical functionality Short Physical Performance Battery (SPPB) (link) Risk of falling Falls Self-efficacy Scale (FES-I) (link) Questions:

• Did you fall in the past 12 months?
• Are you afraid of falling?

Polypharmacy Medication Risk Questionnaire (MRQ-10) (link)

CLINICAL PLAN PREVENTION PLAN

E X P E CTED R E S U LTS

E X P E C T E D R E S U L T S

• Reduction of functional status loss (according to the patient’s clinical

trajectory)

• Reduction of avoidable/unnecessary hospital admission
• Reduction of hospitalization’s adverse outcomes rate
• Reduction of readmission rate
• reduction of unnecessary diagnostics and adverse outcomes related to

pharmacotherapy

• healthcare delivery optimization and savings

E X P E C T E D R E S U L T S

• better cooperation and communication between primary healthcare

professionals and geriatric professionals to deal effectively with problems associated with frailty and comorbidity

• increased patient and informal caregivers’ empowerment and self-

management

• more appropriate and timely interventions

E VA L U ATI ON

APPCARE study design

APPCARE model applied to 3.000 patients in 3 pilot sites (2.500 in Treviso, 250 in Rotterdam and 250 in Valencia) INDICATORS to be assessed:

• hospital admission rate
• Reduction of readmission rate
• Incidence of co-morbidity in patients following the preventive paths

• The three pilot sites all meet the objectives, but with two different

approaches, one more focused on clinical aspects and the others more focused on the preventive aspects. Consequently, the foreseen evaluation is a comparison on two different approaches according to the project indicators and according to assessments variables (to see which group of patients is more compliant with their own clinical trajectory).

• The final external evaluation will perform a cost-effective analysis, together

with the assessment of project utility (potential impact on main target groups) and sustainability and a SRoI on Treviso pilot site.

APPCARE study design & evaluation

A P P C AR E A D D E D VA L U E

E X P E C T E D I M P A C T F O R T A R G E T G R O U P

KEEP +75 PATIENTS AS HEALTHIER AS POSSIBLE thanks to:

• Reduction of functional status loss (according to the patient’s clinical

trajectory)

• Reduction of avoidable/unnecessary hospital admission
• Reduction of hospitalization’s adverse outcomes rate
• Reduction of readmission rate
• reduction of unnecessary diagnostics and adverse outcomes related to

pharmacotherapy

B E N E F I T F O R P U B L I C H E A L T H & M S P O L I C I E S

Changes related to population ageing, increasing longevity and significant incidence of multi-chronic condition are likely to raise demand for healthcare. This could push up healthcare spending by 1 to 2% of GDP in Member States by 2050. On average this would amount to about a 25% increase in healthcare spending as a share of GDP. In this particular context, the EU policy “Together for Health” calls for action to address the financial sustainability of health systems to ensure they are sustainable in terms of continuity of service, universal coverage and a high level of quality. APPCARE addresses the need for cost-effective path of care. All the envisaged actions aim at avoiding patients’ unnecessary admission to hospital, and this will significantly contribute to the maintenance of their health status, optimizing at the same time healthcare systems delivery while containing its spending.

E U A D D E D V A L U E

• Promotion of best practices in all participant countries to

better benefit from the already existing positive experiences

• Benchmarking analysis

D I S S E M I NATI ON & S Y N E R GI ES

D I S S E M I N A T I O N & S Y N E R G I E S

DISSEMINATION ACTIVITIES: Disseminated in several events at national and international level

• APPCARE symposiums during the National Congress of the Italian

Psychogeriatric Association

• Mentioned during all the UHCE project presentations by EMC
• SEFAC 7° International symposium “Health for All” in Rijeka

D I S S E M I N A T I O N & S Y N E R G I E S

APPCARE MID-TERM EVENT – Valencia, 9th June 2017

D I S S E M I N A T I O N & S Y N E R G I E S

OTHER POTENTIAL SYNERGIES:

• collaboration for a further deployment of social care and health and social

integration: i.e. support for early stage dementia.

• Expand the preventive care assessment
• Collaboration in the field of Indipendent Living Solutions

Th a n k s f o r y o u r a t t e n t i o n !

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