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Appropriate care paths for frail elderly patients: a comprehensive model [APPCARE] [664689] - Project
Project abstract

Ageing problems are a common challenge for Europe and health systems: higher frail population in need of long term care, chronic conditions requiring complex response from a wide range of health professionals, often characterized by fragmented and not appropriated care.
+65 patients access to ER more frequently; they stay longer to ER usually ending into ordinary admission, with an increasing risks of hospital-related adverse outcomes.
APPCARE project aims at creating a new model for the management of frail elderly people including
-standardized application of Comprehensive Geriatric Assessment (CGA)
-homogeneous and coordinated care pathway, shared among all the involved care givers, traced by the geriatrician on the basis of CGA and performed through the establishment of a care management program
particular hospital admission care path for +75 patients, with short intensive observation period
-close link hospital-territorial care
-frailty prevention program
to demonstrate how an innovative and comprehensive management of complex and co-morbid clinical situations, may maintain patient’s functional status in its clinical trajectory, optimizing health care systems. APPCARE will design the model on the basis of best practices already tested in the involved territories, to evaluate scalability of these existing strategies.
Relevance to 3^ Health Progr.: APPCARE model is built up in order to achieve a complete and coordinated standard of care for frail patients, where all the involved caregivers agree and follow a homogeneous care path traced by geriatric specialist. This is perfectly in line with the addressed topic, reflecting the EIPAHA strategic plan.
It answers the calls for
better cooperation and communication between primary healthcare professionals and geriatric professionals to deal with problems of frailty and comorbidity
reduction of unnecessary hospitalization and prevention of the related adverse outcomes
early diagnosis and screening for frailty risk facto

Summary of context, overal objectives, strategic, relevance and contribution of the action

Ageing problems are a common challenge for Europe and health systems: higher frail population in need of long term care, chronic conditions requiring complex response from a wide range of health professionals, often characterized by fragmented and not appropriated care.
+75 patients access to ER more frequently; they stay longer to ER usually ending into ordinary admission, with an increasing risk of hospital-related adverse outcomes.
APPCARE project aims at creating a new model for the management of frail elderly people including:

- standardized application of Comprehensive Geriatric Assessment (CGA)
- homogeneous and coordinated care pathway, shared among all the involved care givers, traced by the geriatrician on the basis of CGA and performed through the establishment of a care management program
- particular hospital admission care path for +75 patients, with short intensive observation period
- close link hospital-territorial care
- frailty prevention program

to demonstrate how an innovative and comprehensive management of complex and co-morbid clinical situations, may maintain patient’s functional status in its clinical trajectory, optimizing health care systems. APPCARE will design the model on the basis of best practices already tested in the involved territories, to evaluate scalability of these existing strategies.

Methods and means

The project will deploy accordingly to the following steps:

• Analysis of pilot sites’ contexts and review of best practices in the field of integrated management of chronic elderly patients
• Design of the APPCARE model, designed to meet the main challenges perceived, such as the fragmented care management and the long and frequent hospital stays of +75 patients
• Context -adaptation of the model
• Collection of ex-ante and ex-post data to assess indicators
• Evaluation of impact and sustainability of the APPCARE model (including cost-effectiveness analysis), on the basis of the experimentation results

Work performed during the reporting period

The partners carried out a detailed review of best practices of integrated care and prevention for elderly and multi-morbid patients, both inside and outside the Consortium; in the meantime, they deeply analyzed the current situations in the involved pilot sites (Treviso, Rotterdam and Valencia) in order to better define the existing context in which the experimentation will run.
The analysis identified the common challenges the project should address in the field of hospital care, coordinated care and prevention, becoming the driver for the development of the APPCARE model.
The model defines a list of general requirements that has been context adapted in the three pilot sites. For each module, the APPCARE model foresees:

• Regional adaptation in order to answer the needs of different contexts: considering the relevant differences among the three regions participating in the APPCARE project as pilot sites, the procedures have been context-adapted in order to guarantee its validity.
• Repository of good practices, thanks to a local benchmark analysis to gather all existing resources to be taken into account in the definition of the clinical pathways for patients to follow.

• Training for professional on the model: Professionals has been trained in order to carry out the experimentation.

In addition to this, different professionals have been involved in the data collection process. This needs to be centralized by means of a data collection tool specifically developed for the APPCARE model (task of WP10 Final Impact and sustainability) which is now under construction.

The main output achieved so far and their potential impact and use by target group (including benefits)

The experimentation phase started in December 2016 with the first enrolments, so currently no analysis on achieved outputs is available.

Achieved outcomes compared to the expected outcomes

The APPCARE Consortium foresees that the achievement of the mentioned project’s objectives will lead to the following potential outcomes:

• Reduction of functional status loss (according to the patient’s clinical trajectory)
• More appropriate and timely care interventions
• Reduction of avoidable/unnecessary hospital admission
• Reduction of hospitalization’s adverse outcomes rate
• Reduction of readmission rate
• reduction of unnecessary diagnostics and adverse outcomes related to pharmacotherapy
• increased patient and informal caregivers’ empowerment and self-management
• early monitoring of frailty conditions
• healthcare delivery optimization and savings

The experimentation phase started in December 2016 with the first patient’s enrolments, so currently no analysis on impact is available.

Dissemination and evaluation activities carried out so far and their major results

All the dissemination efforts already performed or scheduled are completely in line with the internal dissemination strategy agreed by the partners. One of the main dissemination tool is the project website www.app-care.org, which is now on line with the main information on model development and progresses. Public project documents are available for download and consultation, including the project leaflet. The leaflet illustrates the general requirements of the model, and will be newly released at the end of the experimentation to present project’s main achievement. The English version of the leaflet will be translated and printed by the Consortium to be widespread also at national level.
The first achievement of the APPCARE project will be presented during the project’s public event scheduled in Valencia on June 6-7 2017. Furthermore, the APPCARE model will be discussed during in a dedicated session of the Italian Psycho-geriatric association congress organized in Florence on March 30th-31st 2017.
Besides all the activities to grant a high quality of project management, APPCARE foresees an external evaluation task to be performed by a qualified evaluation body to assess effectiveness, efficiency and utility of the project. The market survey to identify a possible external evaluator is ongoing: the team estimates to appoint it by April 2017 at latest.