Delivering Healthcare to Dependent Individuals: Towards a Joint Care Model using Evidence-based Contributions
For many years home care needs have been associated with the ageing of the population. This is undoubtedly an important factor that determines an increase in the demand for home services, but will not be the only. Projections undertaken by IMSERSO, jointly with other agencies (Eurostat, UN) data show a projection through a significant increase in the proportion of elderly for half of this century (IMSERSO, 2004 and 2006). Specifically run current age 65 or over 17 % and 4 % of older 80 years to more than 30 % and 10 % respectively in the year 2050. This last fact is relevant since people over 80 years have a prevalence of disability and a higher prevalence of cognitive impairment.
Contel Segura Joan Carles. La atención a personas en situación de dependencia: aportaciones de la evidencia en la construcción de un modelo de atención compartida. Index Enferm [periódico na Internet]. 2009 Set [citado 2009 Dez 14] ; 18(3): 176-179. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1132-12962009000300008&lng=pt.
Joan Carles Contel secure 1
1Diploma in health management and master in public management from ESADE. Processes nursing Ambit Costa Ponent, Institut Catalá of health coordinator. Associate Professor of the school of nursing from the University of Barcelona, Spain.
* Contents of the round table developed within the International Symposium on research in Granada, the Andalusian School of public health, held on 4 and 5 October 2007 in nursing community,
The home care environment
Ageing and dependency. For many years home care needs have been associated with the ageing of the population. This is undoubtedly an important factor that determines an increase in the demand for home services, but will not be the only. Projections undertaken by IMSERSO, jointly with other agencies (Eurostat, UN) data show a projection through a significant increase in the proportion of elderly for half of this century (IMSERSO, 2004 and 2006). Specifically run current age 65 or over 17 % and 4 % of older 80 years to more than 30 % and 10 % respectively in the year 2050. This last fact is relevant since people over 80 years have a prevalence of disability and a higher prevalence of cognitive impairment.
Ageing analysis is complemented with the analysis of theevolution dependency. Existing studies suggest that an increase in the number of elderly does not imply a parallel increase in elderly dependents directly proportionally. Some data based on the "theory of compression of morbidity" point to a discrete decrease in the prevalence of dependency. This adds a new variable to be analyse and study their behavior along the length of time (Fries, 2003; Casado, 2007 López Casasnovas, 2007). Studies with large samples to observe time trends, causes that are associated with the evolution of dependence are required and the identification of preventive interventions with greatest scientific evidence in relation to their impact on it (fries 2003).
Increase people with chronic diseases. Another aspect to consider is the impact of the increase of chronic diseases. There are projections that it provides a significant increase in hospital admissions not scheduled as a result, especially in chronic processes as COPD, ischemic heart disease and heart failure (Dr. Foster, 2006). Some study conducted in our country also noted that the factor that is associated with greater intensity home visit is the presence of ulcers by pressure, while increasing levels of co-morbidity does not necessarily generate greater intensity of home, visits while identified as the main factor related to the increase of unplanned hospital admissions in patients included in (2006 Sylvia) home care program. The development of the British Health Department 3000 new cases (Community Matrons) managers is directed patients complexes or risk with a clinical profile of co-morbidity with multiple chronic diseases at once. One of the most relevant data was in most cases when information systems detect these patients, they were not included in home care programs for community nurses district (Hutt, 2003; Gravelle, 2007).
This analysis also translates into an estimated increase of costs in the healthcare and long-term care ("long term care") between 3.5 and 6 % of GDP during the period 2005-2050 (OECD, 2006).
Extension home services: is there sufficient coverage? Within the primary care are currently available coverage around 6 % of people over 65 years on health-based care programmes. Literature gives us many descriptions of the type of service that is currently offering from computers primary care (Contel, 1999; Institute of health Carlos III, 2002). We know that users of these programs are mostly older middle ages range between 78 and 81 years, have co-morbidity situations, the coverage would be between the 5.9 and 9.14, with an intensity that do not reach 10 visits per patient per year being service 2/3 parties visits by community nurses.
In the case of the social character (type personal and domestic activities help) home care coverage is very low compared with other countries of the European Union, 3.5 % of people over age 65 who receive these services, until recently in a charity coverage or "charity" environment. The intensity is situated in 16 - 18 hours/month per patient (compared to a range between 50 - 150 hours/month in Germany) it must be there are higher than 10 % and 15 % and intensities service significantly exceeding those of our country (IMSERSO 2004) coverage in some countries of our environment.
With the new law of the unit would be this time at the start of a phase incorporates a new model of universal, although still of progressive implementation coverage, where incorporates public funding although in these years moderate dependencies is excluded but which has not proposed the construction of a model public health integrated persons dependent care.
The environment European. In the 1980s some EU countries experienced a rapid growth of the elderly population and devoted considerable economic efforts to the creation of institutions, most of them to detain the elderly permanently. Many Governments recognize that they committed great error, since excessively chose by a model based on residential care (Coleman, 1995).
Later dismantled many of these institutions or in the best cases, transformed into residential models more open and permeable to the community and reoriented the allocation of resources towards the home care sector to develop a comprehensive services in the community, offering will be the case for Dutch replacement policies.
Although all developed countries face problems of ageing and increase of dependents at home, there are large differences in regard to the history of home care and how as it is organized. One of the most important features is the trend towards higher collaboration, cooperation and integration (in some cases "merger") of home health care services and support, on-site services often provided by separate organizations, financed and organized by separate (Leichsenring 2003).
The evidence on the home care
Is home care cost-effective? Home care as a "cost-effective" than other more residential forms apart from other considerations as they would be the freedom and the right of people to live in their natural environment for as long as possible alternative has traditionally been presented. Some authors have attempted to show that in some cases, especially in people living alone with high levels of incapacity or services, intensity requirement is not always a more cost-effective alternative.
Another area where there have been studies of interest is in the assessment of the cost effectiveness of professional services which ensured the continuity of care between hospital care and the Community (computers providing transitional care, nurses link, etc). One of the most important work is carried out by Naylor that showed how a transitional care intervention could drastically reduce the number of readmissions, days of hospitalization and the post-alta cost of patients included in the study (Naylor, 1999). (Also a recent review pointed out that only those experiences high combined with a certain intensity services during the immediate postalta planning has a certain impact on some indicators as readmissions, improves functional ability) (Mistiaen 2007).
In the area of case for patients at complexity management clinic and dependence there is also a rich contribution of reviews and studies that provide no conclusive evidence in the implementation of these programs (Hutt, 2004; Gravelle, 2007) case management.
Preventive home visit. During the Decade of the 1990s there has been much discussion on the effectiveness of preventive visits to the elderly at home. One of the jobs with greater interest is meta-analysis published in JAMA by Stuck. In general terms implementation of household views proactively programs not produced a decrease in mortality in the number of income in residences and containment of the deterioration of the personal autonomy of older persons included in these programs. Only when carried out a subanalyses shown a positive impact on the three mentioned above, specifically in the elderly group indicators younger and when performing an intensity of home visits in excess of nine visits per patient. There are limitations discussed by authors in relation to selected as the little information available regarding the type and intensity of intervention made, the degree of compliance by patients behaviours and habits recommended by professionals and the appropriate selection of population target studies studies.
Ultimately does not seem that there is sufficient evidence to show that implementation of comprehensive preventive, from community services, home health programmes have a reasonable profit for the elderly population in general. More research must be made to estimateWhat kind of target population could benefit more specifically these interventions,what intervention and with what intensity produces evidence to justify putting up of Community programmes (Stuck, 2002).
The future: new models of home care
La hospitalization on-site. Modalities for further expansion is having in recent years in our country home care is the inpatient on-site (HD). This could be defined as a service provides care and care in the home of the patient with an intensity and frequency comparable to that which would have provided within the framework of a conventional hospitalization. Patients served by these units present a situation of clinical stability and have not submitted any indicator criteria of bad evolution in their medical or surgical process. Those patients who have a high risk of suffering a complication are generally excluded.
In our country has been associated the concept of HD to an activity in which the hospital is the only entity capable of carrying it supplier out. Reviewing the international literature notes that this is not always the case. According to the orientation of the health system there are different models of HD programmes exist models in which these services are carried out by community nurses. On the other hand more favourable evidence from the point of view of cost-effectiveness would be in the form in which the patient enters these programs directly avoiding hospital admission (Shepperd 2007). A less favorable evidence in the form of HD which produces a conventional hospital admission with early high followed by monitoring carried out by these programmes.
It seems difficult to think that before the financing of the hospitals system "to do" (payment by case-mix) and primary care by budget ("be"), difficulties in obtaining new investments to increase beds and the emphasis on increasing the number of high, hospitals not increased significantly in the coming years the implementation of these programmes even if enough evidence favorable widespread in terms of cost-effectiveness.
Shared care. While it is clear that primary care teams are one of the major agents who lead the development of home care programs, has increased significantly the number of organizations and professionals involved in health care here. We therefore see how certain lines of service, including care at home, require the adoption of a new health care philosophy. It is in the Anglo-Saxon world called "Shared Care" or in the Netherlands "Transmural Care". In our country a translation that approximates to this concept would probably be "shared care".
This new model care aims to design health services also with social, tailored to the needs of the patient and the family, in the case of the aide on the basis of shared responsibility (administrative, legal and financial responsibility) between organizations and professionals in the health and social system component. This new concept has accompanied a number of experiences in most countries with a good development of home services.
New models in the provision of services. In recent years have been considered and developed processes of innovation that brought new models of service delivery for dependents, with chronic illnesses and situation complexity or risk: chronic care models based on the model of the McColl Institute and models intended to analyze the characteristics of the populations and laminated to act proactively on them with packages of services adapted to your needs. These models contemplarían the following ingredients:
-Evaluation of needs of the population estratificando this base to a predictive model: model Kaiser, Evercare, Pfizzer.
-Redesign (in some cases re-engineering) model to provide services based on the level of complexity obtained by the stratification model (king ' Fund, 2006; Sylvia's, 2006).
-Design of models "case management" for people in situation of complexity or risk (co-morbidity, intensive use of services, moderate or severe dependency pattern).
-Development of integrated care processes that include suppliers health, social, patients and carers.
-Development of an information system shared with hospital care and primary care (common CMDB) data.
-Implementation of expert clinical decision support systems.
-Approximation to a model integrated assessment and follow-up of dependent patients.
-Promotion of primary care and community nurses in this transformation process leadership.
Of all these new levers of change in the configuration of new health care models are beginning to display interesting evidence (Singh 2006).
Community nurses are available to lead the implementation of quality home services. Complex patients or dependent care is probably one of the areas that can bring greater value to their development and maturity as a profession. However this challenge is added to another is the ability to know networking in a pop-up and complex sector. A quality home care necessarily pass through the sum of efforts and attention shared among different organizations, agents and professionals working in the community. The unilateral search for more efficient organizations can lead to the development of geocentric organizations. Why should encourage it and finance the development and deployment of common and cross-sectoral projects.
Address for correspondence:
Manuscript received the 23.12.2007
Manuscript accepted the 27.8.2008
Joan Carles Contel Segura