P-454: 'Center for Geriatric Care': development of the novel care model for elderly patients in Gdansk, Poland. Presentation of the project and pilot study

摘要

Integration of care for elderly is a necessity reflecting aging Central-European populations and low effectiveness of present care systems for seniors. The "Center for Geriatric Care" (CGC) project assumes development of novel, home-based model of care in patient-centred triangle consisting of healthcare providers—social workers—family. In CGC standard healthcare and social services will be broadened by periodic evaluation by geriatricians, regular home visits of specially trained carers, regular rehabilitation sessions based on physiotherapy, and simple e-health interventions. In the pilot study the CGC model will be delivered to 90 multimorbid elderly, recruited from three different healthcare pathways (primary care, n = 30; patients with chronic heart failure, n = 30; patients with chronic obstructive pulmonary disease, n = 30). The primary outcome of the project is to design integrated care model, which is innovative in Poland, and to test whether it has an impact on patients' functional and cognitive status, quality of life, demand for medical services, especially in-hospital, and selected health economics indicators. Secondary outcome is to increase the knowledge and competencies of social workers, nurses, physiotherapists, medical careers and family members on the management of elderly chronically ill patients, and to improve cooperation between these groups and medical staff. Since 2019 the pilot study is ongoing. The current work gives an insight into the project advances and provides background for expert discussions. Acknowledgment: The CGC project has received funding from European Union under Regional Operational Programme of the Pomerania Voivodeship 2014-2020.