Delivering integrated care for older people with frailty

The conference was focused on the ways in which integrated care can be delivered for older people with frailty, looking at interactions between acute, primary, community and social care services, older people living with complex co-morbidities and ways in which older people with frailty can be supported to maintain their health and wellbeing.

Presentations are available in this link: Delivering integrated care for older people with frailty 

ValueCare: Cork/Kerry Pilot Site

Use of Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) for the screening of frailty and components of comprehensive geriatric assessment

Comprehensive geriatric assessment (CGA)—a key tool for geriatric medicine—is commonly used to assess older people’s health status and frailty. However, performing CGA in outpatient clinics is difficult because the assessment of cognition, activities of daily living (ADLs), depression, quality of life (QoL), nutrition, medications and social conditions is time consuming and requires the cooperation of medical staff. Frailty—an aspect of geriatric medicine that indicates the weakness of the body—is a critical measure of older adults’ physical function.

The Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) is a validated and simple rating scale, developed for the classification of setting glycemic targets based on cognition and ADL for older adults with diabetes mellitus. As cognitive function and ADL are key elements of frailty in a broad sense and in CGA, we examined whether the DASC-8 category is useful for the ...

Effect of an integrated care model for pre-frail and frail older people living in community

The objective of this article is to evaluate the effect of an integrated care model for pre-frail and frail community-dwelling older people.

JICA Special Issue: Integrated Palliative and End of Life Care for People with Advanced Dementia or Frailty

This special issue now seems uncannily prescient in view of the devastating impact of COVID-19 on people with advanced dementia or severe frailty, particularly in care homes.

The pandemic has heightened awareness of the possibility of a sudden and rapid transition from relative health to a palliative or end of life stage. This has opened up conversations about the potential burden from intensive treatments that are likely to be futile and the benefits of advance care planning.

The collection of papers in this special issue will be of interest to readers involved in planning, commissioning or delivering palliative and end of life care services for our most vulnerable citizens at this time, whether at home or in a hospital, care home or hospice.

Read the full Guest Editorial and the collection of papers of this special issue

The Seniors' Community Hub: An Integrated Model of Care for the Identification and Management of Frailty in Primary Care

Integrated models of primary care deliver the comprehensive and preventative approach needed to identify and manage frailty in older people. Seniors' Community Hub (SCH) was developed to deliver person-centered, evidence-informed, coordinated, and integrated care services to older community dwelling adults living with frailty. This paper aims to describe the SCH model, and to present patient-oriented results of the pilot.

Barriers and Facilitators in the Uptake of Integrated Care Pathways for Older Patients by Healthcare Professionals: A Qualitative Analysis of the French National “Health Pathway of Seniors for Preserved Autonomy” Pilot Program

Integrated care is a particularly promising approach in geriatrics – a field in which the medical, psychological and social issues are often complex. The uptake of integrated care by healthcare professionals is essential but varies markedly.

The objective of the present study of healthcare professionals was to identify barriers to and facilitators of commitment to integrated care for seniors.

World Health Organization Integrated Care for Older People (ICOPE) and the Integrated Care of Older Patients with Frailty in Primary Care (ICOOP_Frail) Study in Korea

The World Health Organization (WHO) recently endorsed the proposal for a Decade of Healthy Ageing (2020-2030). The WHO defines "healthy aging" as "the process of developing and maintaining the functional ability that enables wellbeing in older age." Among the strategies for the Decade of Healthy Ageing, the WHO has suggested enhancing intrinsic capacity, promoting functional ability, and implementing the Integrated Care for Older People (ICOPE) package. The WHO has defined steps for ICOPE evaluation and scale-up and is performing a prospective study in 2-3 countries (low and middle income, high income) to test its feasibility in 2021-2022 and a multinational randomized study to validate its clinical efficacy and effectiveness in 2022-2024. Intrinsic capacity and frailty represent two faces of the same coin, with one indicating the reserves of the individual and the other indicating the deficits that accumulate with age. The Integrated Care of Older Patients with Frailty in Primary ...

The Contribution of Case Mix, Skill Mix and Care Processes to the Outcomes of Community Hospitals: A Population-Based Observational Study

Community hospitals could address the emerging complex care needs of patients. The authors investigated which characteristics of patients and community hospitals affect patient outcomes, in order to identify who could benefit the most from community hospital care and the best skill mix to deliver this care.

What matters most in acute care: an interview study with older people living with frailty

Healthcare outcome goals are central to person-centred acute care, however evidence among older people is scarce. Older people who are living with frailty have distinct requirements for healthcare delivery and have distinct risk for adverse outcomes from healthcare. There is insufficient evidence for whether those living with frailty also have distinct healthcare outcome goals. This study explored the nature of acute care outcome goals in people living with frailty.

The Care Coordinator’s Tasks During the Implementation of an Integrated Care Pathway for Older Patients: A Qualitative Study Based on the French National “Health Pathway of Seniors for Preserved Autonomy” Pilot Program

Although integrated care and care coordination are known to be beneficial for older adults’ population, the specific tasks of a Care Coordinator (CC) for integrated care pathways for this population have not been studied in detail. In this study, the CC’s tasks in an integrated care pathway for older adults shows that the CC’s overall workload was greater than expected and appreciated by healthcare professionals.

Models of integrated care for older people with frailty: a horizon scanning review

Frailty, a multifaceted geriatric condition, is an emerging global health problem. Integrated care models designed to meet the complex needs of the older people with frailty are required. Early identification of innovative models may inform policymakers and other stakeholders of service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. This study used horizon scanning methodologies to systematically search for, prioritise and assess new integrated care models for older people with frailty and investigated experts’ views on barriers and facilitators to the adoption of horizon scanning in health services research.

Effectiveness of a community-integrated intermediary care (CIIC) service model to enhance family-based long-term care for Thai older adults in Chiang Mai, Thailand: a cluster-randomized controlled trial TCTR20190412004

Populations around the world are ageing faster, with the majority living in low- and middle-income countries where health and social care are yet to be universal and inclusive for the ageing population. This community-integrated intermediary care (CIIC) model is a novel prevention-based, long-term care model enhancing the family-based care system traditionally practised in Thailand and neighbouring Asian countries, and many low-and middle-income countries globally. This study assessed the effectiveness of the CIIC model in Chiang Mai, Thailand.

Integrated Care for Older People with Different Frailty Levels: A Qualitative Study of Local Implementation of a National Policy in Luton, England

The NHS England General Medical Services 2017-18 contract made it mandatory for general practices in England to identify and manage older people proactively. In response to the national policy, the Luton Framework for Frailty (LFF) programme was developed to target older residents of Luton and offer interventions according to their frailty level. The aim of this study was to gain a deeper understanding of the LFF and the factors that affect the implementation of a proactive integrated care service for older people with different frailty levels (OPDFL).

Use of a Self-Report Electronic Comprehensive Geriatric Assessment by an Interprofessional Integrated Care Team to Support Older Adults Living with Frailty: A Pilot Project

Comprehensive geriatric assessment (CGA) is effective in supporting older persons with frailty, though access remains limited by human resource shortages. We investigated the feasibility and acceptability of a self-re- port CGA instrument to support care planning by an Integrated Care Team (ICT).