Staged Model of Care – the key to the best point of service in geriatrics

摘要

Background : With reference to the demographic change and the growing number of the elderly, inappropriate health care bears a great challenge for geriatric care management and especially for the health care expenditures. Inappropriate health care may refer to unnecessary medical interventions which, on the one hand, relate to unjustifiably high costs in health care systems, and on the other hand, leads to an inadequate supply of geriatric patients, with high risks of reducing their quality of life. Considering that, the need for improving individual pathways as well as the quality of an integrated geriatric care management should obtain high priority within policy developments. The Geriatric Health Care Centers (GGZ) have built up different departments in order to offer a Staged Model of Care for all geriatric patients to provide the best possible and demand-oriented care for this particular target group. The GGZ run more than 10 inpatient, part-inpatient departments and day care units for geriatric patients. Methods : In order to analyze the effectiveness of this Staged Model of Care for geriatric patients, a study was performed. The patient population includes a total number of 6120 geriatric patients (average age: 82 years, average number of diagnosis 5), who were treated in one of four different inpatient departments of the GGZ (Acute Geriatric Care Unit, Intermediate Care Unit, Medical Geriatric Care Unit and Nursing Homes) between January 2014 and December 2015. The study is based on indicators such as the average length of stay, the Barthel Index Score, the incidence of falls and pressure ulcers, staffing in full-time equivalent per patient and the therapeutic services per patient. In addition to the comparative evaluation study, a process analysis of the Comprehensive Geriatric Assessment prior to admission was conducted. Based on three documents–a process description of the different departments, the patients’ registration forms and referral criteria–three different interdisciplinary assessment teams (#1: Acute Geriatric Care Unit, #2: Intermediate & Medical Geriatric Care Unit, #3: Nursing Homes) decide on the admission of patients to a specific department. The performance of a Comprehensive Geriatric Assessment prior to admission is appropriate to ensure an adequate multidisciplinary treatment and achieve the aims of treatment. Results : The results of the study show that the indicators reflect the structure of care and the aims of treatment through the different stages of care. Within the departments Acute Geriatric Care and Intermediate Care Unit they focus on remobilization with the aim of discharging patients home or to institutions with lower care intensity. Therefore the indicators show that the average period of hospitalization is much shorter (approx. 20 days) than in long term care institutions, e.g. the Medical Geriatric Care Unit (approx. 147 days) or in Nursing Homes (approx. 635 days). In comparison to long term care units therapeutic services are provided more often to patients at the Acute Geriatric Care Unit and Intermediate Care Unit (approx. 0.7 hours/day). The indicators of staffing also demonstrate that there is no need for the attendance of physicians 24/7 in Nursing Homes. This is due to the fact that it is a residential facility where quality of life until one’s death and caregiving has priority. At the Acute Geriatric and Intermediate Care Unit the number of physicians in full-time equivalent per patient (approx. 0.12) is much higher than in Nursing Homes (approx. 0.02), because the patients’ general health condition has to be compiled first to give therapy advices and regain the patients’ independence by increasing their health literacy. Conclusions : To conclude, it can be said that the intensity of care in each stage of supply correlates with the demands and needs of geriatric patients. Therefore it provides the best point of service not only for patients but also achieves health economic advantages (e.g. usually adequate care can be offered at lower daily fees than in acute hospitals). Moreover, this Staged Model of Care allows, if necessary, the exchange of patients within the organization. A decision-tree is designed to keep high quality standards and facilitate the admission assessment for new employees. For this purpose factors of patient groups are defined in order to allocate patients more easily to different units of care (e.g. high remobilization potential as an indicator for the Acute Geriatric Care Unit etc.). However the findings show a definite need of further development towards home care concepts like ambulatory or mobile care services.