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13 January 2019
Abstracted by Dr. Nabil Kronfol, President, Lebanese HealthCare Management Association; Professor: Health Policy and Management; American University of Beirut, Lebanon
In 2015, the World Health Organization (WHO) published the first world report on ageing and health. This was followed in 2016 by the World Health Assembly’s adoption of a global strategy and plan of action on ageing and health. Both documents reflect a new conceptual model of healthy ageing that is built around the functional ability of older people rather than around the absence of disease. At the same time, the United Nations adopted the 2030 Agenda for Sustainable Development.
These documents call for major reforms to health and long-term care systems and for the prioritising of interventions that optimise older people’s physical and mental capacities over their life course.
As people age, their health issues tend to become more chronic and complex and older people can develop complex health states (frailty, increased risk of falls). If not properly managed, these conditions can lead to polypharmacy, hospitalisation and death. Providing care for older people is also increasingly complex with the involvement of many types of health workers. Healthcare services to the older population will need to serve people with a high and stable level of intrinsic capacity, those with a declining capacity and those whose capacity has deteriorated and thus require additional support.
Instead of trying to manage numerous diseases and symptoms in a disjointed fashion, several countries are placing increasing emphasis on interventions that optimise older people’s physical and mental capacities over their life course. This requires greater integration within the health system and between health and social services to provide a coordinated service. Evidence suggests that this integration leads to better health outcomes at the same or even lower cost.
At the level of clinical care comprehensive assessments are recommended in order to optimise the functional ability of the seniors. This requires supportive policy, plans and regulatory frameworks, workforce development, improved communication technologies; and pooled and bundled payments (with incentives if necessary).
Emphasis ought to be on the older person’s physical and mental capacity and the starting point for, coordinated health interventions.
WHO’s approach hinges on the premise that care can be integrated at: (i) the macro level (i.e. at the policy or sector level); (ii) the meso level (i.e. at the organisational or professional level); or (iii) the micro level (i.e. at the clinical or interventional level). In addition, it is also older person-centred, aimed at individuals with unique needs and preferences, as members of a family and a community.
The framework proposes five interdependent strategies that must be implemented to enable health services to become more people-centred and integrated: (i) engaging and empowering people and communities; (ii) strengthening governance and accountability; (iii) reorienting the model of care; (iv) coordinating services within and across sectors; and (v) creating an enabling environment.
There is also a lack of consensus on what constitutes a positive outcome for older peo¬ple. Traditionally, healthcare research has used indicators of disease, disability, longevity, patient and provider satisfaction, healthcare utilisation, hospitalisation, institutionalisation and cost. In contrast, the main aim of integrated care for older people is not to manage disease or prolong life but is, instead, to optimise older people’s intrinsic capacity over their life course and, hence, ensure healthy ageing.
A different set of outcome indicators is needed – indicators that reflect intrinsic capacity, functional ability, quality of life and the attainment of goals defined by the older person. Finally, only a few easily accessible, policy guidance and implementation tools exist.
Requirements for Integrated Care
Achieving the goals of WHO’s global strategy and plan of action on ageing and health requires political commitment to integrated healthcare for older people, the development of coherent health systems policy, and normative guidance on the implementation and evaluation of integrated care both nationally and internationally.
To achieve best outcomes for older people, one should organise care around the concerns and priorities of older people themselves — and integrate the assets, which can contribute to healthy ageing (strengths of the older person, family care, support from local resources).
A comprehensive approach is needed to understand the complex factors contributing to the older adults needs and to integrate care around the specific priorities and goals of the older person. Personalised approaches in care emphasise the empowerment of the older persons and their families to participate in making decisions about their health.
An essential strategy to attain integrated, people-centred health services is to build strong primary care-based systems due to their outreach to the wider population of older adults in the community. This approach involves not just multidisciplinary health professionals but a range of other formal and informal caregivers. The gold standard in assessment of older people is comprehensive geriatric assessment.
In many people’s lives there will come a stage when they experience a significant loss of mental or physical capacity, particularly in old age. The functional ability of the older persons is determined not just by an individual’s capacities, but also by the environments they inhabit and the care and support that is available to them.
The term “long-term care” describes the full range of efforts, all directed to ensure the best possible trajectories of an individual’s capacity and functional ability over time. WHO defines long-term care as “all activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity.”
“Long-Term Care is About People, Not About Services”
An effective system of long-term care will also ensure that all caregivers are adequately trained and supported. Educational curricula need to be tailored to ensure graduates have the skills and understanding necessary to fill their role, and continuing professional development will be important if professional caregivers are to maintain them. Many paid caregivers have received little training and an effective system of long-term care can ensure general standards in the paid workforce and might establish accreditation mechanisms to ensure staff and care providers develop and maintain appropriate competencies. Moreover, since most care is provided by family caregivers, a core element of any system must be to ensure they receive adequate training, are supplemented where necessary with professional support and have access to services such as respite care.
WHO (2017) has identified three global actions that can facilitate the development of long-term-care systems:
a. Building understanding and commitment to developing long-term-care systems.
b. Mapping the current situation in long-term-care provision
c. Providing guidance and technical assistance for countries at all levels to meet the needs of adults with significant losses of capacity.
This concept paper has benefited from four background papers made available at the Global Consultation on Integrated Care for Older People: The Path to Universal Coverage and from the symposium of the Global Alliance for Musculo-skeletal Health on “The Importance of Musculo-skeletal health for Healthy Ageing”.
References available on request.