Fully integrated care for frail elderly: two American models

Abstract

PurposeIntegrated care for the frail elderly and other populations with complex, chronic, disabling conditions has taken centre stage among policymakers, planners and providers in the United States and other countries. There is a growing belief that integrated care strategies offer the potential to improve service co-ordination, quality outcomes, and efficiency. Therefore, it is critical to have a conceptual understanding of the meaning of integrated care and its various organisational models, as well as practical examples of how such models work. This article examines so-called “fully integrated” models of care in detail, concentrating on two major, well-established American programs, the social health maintenance organisation and the program of all-inclusive care for the elderly.TheoryA major challenge to understanding the performance and outcomes of fully integrated care and other organisational models is the lack of a meaningful, analytical paradigm. This article builds upon the work of Walter Leutz, to develop a framework by which new and existing programs can be analysed. This framework is then applied to the two American models that are the focus of this article.MethodsExisting data about integrated care in general, and the two model programs in particular, were collected and analysed from reports published by governmental and non-governmental organisations, and journal articles retrieved from Medline, HealthStar and other sources.Results and conclusionsThis analysis strongly suggests that fully integrated models of care, such as the social health maintenance organisation and program of all-inclusive care for the elderly, are not only feasible, but offer significant potential to improve the delivery of health and social care for frail elderly patients. In addition, the authors identify the factors that are the most critical to the success of fully integrated care, and offer lessons for their development and implementation. Finally, issues are raised concerning the transferability of this complex model to other countries, as well as the vital importance of evidence-based evaluation research in furthering the evolution of integrated care.

A service model of short-term case management for elderly people at risk of hospital admission

“…4 (p. 20) Despite this, staff perceived considerable improvements in integrated service delivery. Their capacity to be responsive to client needs, their increased understanding of Models of Care agencies in other sectors and greater collaboration between them were rated as much improved in the current service model.…”

“…These findings have been noted in another study and related to the possible effects of better medical detection and follow up, and situational factors in transitioning between hospital and nursing home. 4 The program evaluation did not include a comparison between those clients who had received a geriatrician assessment and those who had not. This is a research question to be considered in the future.…”

“…Where full integration is part of the program design, extensive benefits and success on a range of indicators, including reductions in hospital admission and bed occupancy as well as positive patient outcomes such as high satisfaction ratings and quality of life measures, are possible. 4 Another determining factor is the degree to which the program specifically targets those chronically ill, elderly people either exhibiting, or "at risk" of repeated hospital admissions. Selection into the target group is based on a comprehensive assessment of health and social "risk" factors.…”

“…4 These studies used a number of indicators to measure the success of their intervention to reduce unplanned hospital use. Hospital readmissions over time, combined rates of death and readmission, emergency department presentations over time, admissions to wards from emergency departments, and length of hospital stays have been reported and criticised.…”

Collaborative nurse practitioner and physician health care service provision for at-risk seniors in Fort St. John, B.C.

“…Integration of health care services became a buzz word in the 1990's as it was recognized that health care service provision was fragmented with disjointed care, less than optimal quality, system inefficiency and difficultto-control costs (Kodner, 2000). Integrated care is defined by Kodner and Spreeuwenberg (2002) as a "discrete set of techniques and organizational models designed to create connectivity, alignment, and collaboration within and between the cure and care sectors at the funding, administrative and/or provider level" (Kodner and Spreeuwenberg (2002) as cited in Kodner, 2006, p. 385).…”