Dossier n. 218/2012 [Abstract] Multidimensional assessment of elderly patients

One of the priorities set by the Emilia-Romagna Regional Health and Social Plan focuses on care for the elderly and vulnerable subjects. A complex system and articulate answers have been implemented to respond to the growing number of individuals with specific care needs.

The concept of continuity of care - defined as the process by which patients and physicians actively cooperate in health care management - extends beyond the interpersonal aspects of care, and it can be seen as prolonging the physician-patient relationship; such perspective cannot be separated by a quality and cost/efficiency assessment of services. It is therefore an ongoing care relationship, focused on patients’ individual needs, on communicating and managing pathologies in the wider context of patients’ life (Tarrant et al., 2006). A well-functioning continuity of care is associated with a reduced risk of hospitalization in elderly patients (Counsell et al., 2007; Menec et al., 2006).

At the same time there is a need to improve care quality, which has objectively reached significant levels of complexity aggravating the critical elements constituted by the integration in the system between the various components of service delivery. Ensuring continuity means promoting the centrality of patients in health care management (Haggerty et al., 2003), but not only by placing patients at the center of a service system: Shortell (1976) already defined continuity of care as “the extent to which medical care services are required as a coordinated and uninterrupted succession of events consistent with the medical care needs of the patients”. More recently the emphasis has been placed on the vertical integration of health care services, ranging from the specialistic areas of hospital facilities to the context of primary care (Gulliford et al., 2006). The perception of continuity of care, i.e. the continuous and coordinated progression of care, is a key element in patients’ satisfaction (Freeman et al., 2003) and, especially for chronic patients, it is more affected by the health care model than by the pathology itself (Cowie et al., 2009).

Getting into the details of the health services network and verifying its effectiveness and appropriateness appears therefore as a priority, especially in the light of changes within patients’ population. It is not so much a question of assessing the services’ degree of integration, but rather of understanding the extent to which the articulation of a health care pathway affects patients’ quality of life. For example, previous European researches have assessed the condition of self-management programs by chronically ill patients (Elzen et al., 2007), but without conclusive results.

In this regard, this Dossier presents the results emerging from the project “Continuity of care: application of a minimum data set for the assessment of elderly patients and health care pathways” (conducted in Emilia-Romagna in 2008-2009). The project involved the development and testing of a minimum data set for the assessment of elderly chronic patients, in order to compare of homogeneous health care settings, services’ appropriateness, and estimates of vulnerable subjects’ care needs. The project consists of several research centers converging towards the same goals, even if characterized by specific contributions.

The current situation, in terms of health care for elderly patients - especially if not self-sufficient - highlights several critical issues. Some of these are related to health care processes, including:

• the difficulty to provide continuity of care;
• the difficulty in integrating social care and health care;
• the qualification of care in nursing homes, which today are evaluated by number of beds rather than by their projects.

Other critical issues are related to the ability to measure health care outcomes, particularly as regards:

• the demand to focus not only on satisfying elderly patients’ care needs, but also on the ability to preserve their residual skill;
• the difficulty to fully assess patients’ needs, in order to define an appropriate health care pathway in terms of which professionals should be involved. This stems in part from the inability to extend the methodology for multidimensional assessment to all care settings;
• the limited ability of nursing facilities to monitor and assess health care outcomes defined in individual care plans for patients;
• the difficulty of collecting a systematic and consistent database allowing comparisons between different settings;
• the lack of an ongoing and appropriate case mix evaluation in nursing facilities, which doesn’t allow us to understand the evolution of needs and, consequently, the adequacy of service delivery.

It is well known that developing needs assessment tools, using them as a reference for preliminary examinations, and administering them repeatedly in a specified time frame allows us to:

• estimate outcomes achievement;
• plan interventions;
• prove accomplishments;
• implement monitoring systems to highlight and intercept events that could be read as outcome indicators, and potentially avert clinical risks.

The assessment tool developed for our project was based on three methodological principles; it should therefore be:

• multidimensional: outcomes must be assessed on a range of clinical and psychosocial indicators;
• multi-axial: outcomes must be assessed accounting for different points of view, as health care processes involve different subjects (e.g. patients, physicians, health care operators, families and so on);
• longitudinal: outcomes must be repeatedly assessed through prolonged periods of time.

The reliability of data will allow us to introduce specific synthetic indicators in the existing regional information flows, and model evaluation will allow us to identify requirements to be included in the regional government system. We may also set up feasibility plans to extend the use of the minimum data set to all the nodes of the health care network.