Matthieu de Stampa

A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly

Despite strong evidence for the efficacy of integrated systems, securing the participation of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel approaches are needed to resolve these problems. We developed a model — COPA — that is based on scientific evidence and an original design process in which health professionals, including PCPs, and managers participated actively. COPA targets very frail community-dwelling elders recruited through their PCP. It was designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits and hospitalizations, and prevent inappropriate long-term nursing home placements. The model’s originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment and care plan development; 2) having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the PCP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community to see patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions. Since COPA is currently the subject of both a quasi-experimental study and a qualitative study, we are also providing preliminary findings. These findings suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results indicate that the level of service utilization in COPA was less than what is reported at the national level, without any compromises in quality of care.

Patterns of Loss of Abilities in Instrumental Activities of Daily Living in Alzheimer’s Disease: The REAL Cohort Study

Background/Aims: To determine patterns of loss of abilities in instrumental activities of daily living (IADL) in community-dwelling women with Alzheimer’s disease (AD). Methods: Sixteen French university hospitals included 471 consecutive women with mild to moderately severe AD (Mini-Mental State Examination scores between 10 and 26) from April 2000 to June 2002 in the noninterventional REAL cohort. At inclusion, 6 and 12 months, IADL were assessed with the Lawton scale. Patterns of loss of abilities in the 8 IADL of the Lawton scale were described using Lawton binary grading. Results: At inclusion, 56.7% of the patients shared the same pattern of loss of abilities and 84.3% had this pattern or variants of it. Frequencies of the 8 incapacities were: 80.7% to do the grocery shopping, 76.0% to take medication, 72.2% to prepare meals, 41.4% to travel on public transportation even when assisted, 40.6% to manage purchases, 30.1% to launder small items, 14.2% to participate in some housekeeping tasks and 11.0% to answer the telephone. Conclusion: In this study including 471 community-dwelling women with AD of the French REAL cohort, the loss of the 8 IADL, assessed with the Lawton binary grading, was homogeneous for more than four fifths of the patients.

Impact on hospital admissions of an integrated primary care model for very frail elderly patients

Very frail elderly patients living in the community, present complex needs and have a higher rate of hospital admissions with emergency department (ED) visits. Here, we evaluated the impact on hospital admissions of the COPA model (CO-ordination Personnes Agées), which provides integrated primary care with intensive case management for community-dwelling, very frail elderly patients. We used a quasi-experimental study in an urban district of Paris with four hundred twenty-eight very frail patients (105 in the intervention group and 323 in the control group) with one-year follow-up. The primary outcome measures were the presence of any unplanned hospitalization (via the ED), any planned hospitalizations (direct admission, no ED visit) and any hospitalization overall. Secondary outcome measures included health parameters assessed with the RAI-HC (Resident Assessment Instrument-Home Care). Comparing the intervention group with the control group, the risk of having at least one unplanned hospital admission decreased at one year and the planned hospital admissions rate increased, without a significant change in total hospital admissions. Among patients in the intervention group, there was less risk of depression and dyspnea. The COPA model improves the quality of care provided to very frail elderly patients by reducing unplanned hospitalizations and improving some health parameters.

Fostering participation of general practitioners in integrated health services networks: incentives, barriers, and guidelines

BackgroundWhile the active participation of general practitioners (GPs) in integrated health services networks (IHSNs) plays a critical role in their success, little is known about the incentives and barriers to their actual participation.MethodsData were gathered through semi-structured interviews and a mail survey with GPs enrolled in SIPA (system of integrated care for older persons) at 2 sites in Montreal. A total of 61 GPs completed the questionnaire, from which 22 were randomly selected for the qualitative study, with active and non-active participation in the IHSN.ResultsThe key themes associated with GP participation were clinician characteristics, consequences perceived at the outset, the SIPA implementation process, relationships with the SIPA team and professional consequences. The incentive factors reported were collaborative practices, high rates of elderly and SIPA patients in their clienteles, concerns about SIPA, the selection of frail elderly patients, close relationships with the case manager, the perceived efficacy of SIPA, and improved professional practices. Barriers to GP participation included high expectations, GP recruitment, lack of information on SIPA, difficult relationships with SIPA geriatricians and deterioration of physician-patient relationships. Four profiles of participation were identified: 2 groups of participants active in SIPA and 2 groups of participants not active in SIPA. The active GPs were familiar with collaborative practices, had higher IHSN patient rates, expressed more concerns than expectations, reported satisfactory relationships with case managers and perceived the efficacy of SIPA. Both active and non-active GPs reported quality care in the IHSN and improved professional practice.ConclusionThroughout the implementation process, the participation of GPs in an IHSN depends on numerous professional (clinician characteristics) and organizational factors (GP recruitment, relationships with case managers). Our study provides guiding principles for establishing future integrated models of care. It suggests practical guidelines to support the active participation of GPs in these networks such as physicians with collaborative practices, recruitment of significant number of patients per physicians, the information provided and the accompaniment by geriatricians.

Multidisciplinary teams of case managers in the implementation of an innovative integrated services delivery for the elderly in France.

BackgroundThe case management process is now well defined, and teams of case managers have been implemented in integrated services delivery. However, little is known about the role played by the team of case managers and the value in having multidisciplinary case management teams. The objectives were to develop a fuller understanding of the role played by the case manager team and identify the value of inter-professional collaboration in multidisciplinary teams during the implementation of an innovative integrated service in France.MethodsWe conducted a qualitative study with focus groups comprising 14 multidisciplinary teams for a total of 59 case managers, six months after their recruitment to the MAIA program (Maison Autonomie Integration Alzheimer).ResultsMost of the case managers saw themselves as being part of a team of case managers (91.5%). Case management teams help case managers develop a comprehensive understanding of the integration concept, meet the complex needs of elderly people and change their professional practices. Multidisciplinary case management teams add value by helping case managers move from theory to practice, by encouraging them develop a comprehensive clinical vision, and by initiating the interdisciplinary approach.ConclusionsThe multidisciplinary team of case managers is central to the implementation of case management and helps case managers develop their new role and a core inter-professional competency.

The course of physical functional limitations and occupational conditions in a middle-aged working population in France.

BackgroundPhysical functional limitations (PFL) have mainly been studied in older populations. The aim of this study was to better understand the course of PFL and associations with occupational factors by gender in a middle-aged working population.MethodsThe data came from 16,950 workers in the ESTEV (Enquête Santé Travail et Vieillissement) cohort in France. PFL were assessed using the physical abilities section of the Nottingham Health Profile. Occupational conditions were measured with a self-administered questionnaire covering physical and psychosocial factors in 1990 and 1995. Multivariate analyses were used to assess the associations.ResultsThe PFL appearance rate in 1995 was the same by gender (6.3%); the rate of PFL recovery was higher in men (23.9% versus 20.9%). Age was an independent factor of PFL at age 47 years or older in both genders after adjusting for confounding factors. The PFL appearance rate in 1995 was higher with physical occupational exposure in 1990, such as awkward work with a dose relation in both genders, while the PFL recovery rate decreased significantly only for men. Exposure to psychosocial occupational conditions, such as having the means to produce quality work in 1990, was significantly associated with a decreased PFL appearance rate in 1995 in both genders, and having high decision latitude in 1990 was associated with a decreased PFL appearance rate in 1995 only in men. Changes in exposure to occupational factors between 1990 and 1995 were associated with the PFL appearance and recovery rates in 1995 in both genders.ConclusionsAfter five years, the course of PFL in this working population changed and was associated with physical and psychosocial occupational factors. Relationships were stronger for the PFL appearance rate in both genders and were weaker for recovery from PFL, mainly among women.

Use of standardized multidimensional evaluation tools and the emergence of the case manager's professional identity in France.

In France, the national public health plan proposes a group of innovations including the initiation of case management for older adults in complex situations, particularly those with cognitive disorders. In this context, public authorities asked case managers to use a standardized multidimensional evaluation tool. The results of a qualitative study on the pertinence of such a tool relative to the emergence of this new professional field are described. Early use of an evaluation tool seems to be linked to the emergence of a new professional identity for recently recruited case managers. Factors determining the strength of this link are training, tool standardization, computerization, and local structure’s involvement. Our results contribute to identifying one of the ways by which professional identity can be changed to become a case manager.

Patients en situation palliative en hospitalisation à domicile : trajectoires de soins et caractéristiques cliniques

INTRODUCTION The great majority of French people express their desire to receive palliative care at home. The objective of this study was to describe the clinical care pathways and characteristics of patient receiving hospital at home palliative care. METHODS This study compared the care pathways and clinical characteristics of patients receiving palliative care at home in the Ile-de-France region in 2014. Retrospective data were extracted from the French medical information systems programme. RESULTS 817 patients receiving palliative care at home were included in the study. They were older, more often referred to hospital at home by a primary care physician, had shorter lengths of stay and more often died at home compared to patients without palliative care. Palliative care patients mainly presented cancer and received frequent technical nursing care. The oldest patients (≥ 75 years old) more often presented neurodegenerative diseases, were less often transferred to hospital, and more often died at home compared to younger patients. A higher proportion of home deaths was observed in nursing home residents and patients who died at home required less technical nursing care. CONCLUSION This study provides important information concerning admission to hospital at home, the frequent changes of places of care and the complexity of maintaining palliative care at home until the patients death.

Moving toward integrating care in France: factors related to local managers

Purpose The 2008–2012 French Alzheimer plan aims to implement an integrated services delivery (ISD) called “Homes for Integration and Autonomy for Alzheimer patients”. Alzheimer disease is taken as a model to implement ISD in the whole system. All pilot projects were driven by a ‘local pilot’ fully dedicated to the ISD implementation. Methods We aimed to analyze factors related to the ‘local pilot’ in regard of the implementation of the national public health policy. We conducted interviews of all ‘local pilots’ (n=19) in 2010, their project’s structure managers (n=19) and case managers (17 focus groups). We crossed our results with the external follow-up by the national project team. Results Main influencing factors of the ISD implementation were: 1) professional autonomy of the pilot; 2) good positioning of the project’s structure manager; 3) project’s management competency of the pilot; 4) support query by the pilot from the national project team; 5) links between case managers and pilot; and 6) the articulation modality of eventual multiple pilots or managers. Discussion and conclusions It was previously shown that it is crucial for ISD implementation to have a dedicated professional for this task. The French national Alzheimer plan gave us an opportunity to analyze factors related to the modality of doing this task.