The health pathway of the frail elderly people (or with a risk of dependence).
Prof Claude JEANDELa
a Centre Antonin Balmès. CHU de Montpellier
While the part of the elderly people is increasing (in 2050, doubling of the 60 years old, trebling of 75 or more, and fivefold increase of over 85 !), hospitalizations are going to grow of so much and especially for four causes: drug misuse, under-nutrition, depression and falls… while dependence at home will grow. In front of these demographic, epidemiologic, sanitary stakes and facing their financial impact, public authorities put forward the necessary revision of our models of organization.
The model of Health Pathway is put forward as a new structuring paradigm of health and social policy, and of regional health programs. Centered on needs and promoting the personalized approach through the Personalized Plan for Health (PPH), this model has to contribute to make that the elderly people receives the good care, by the good professionals, in the good structures, at the right time and in the best cost.
The High Council for the Future of Health Insurance (HCFHI) puts forward the coordination between the actors of the health system to promote pathways of the Elderly People At Risk of Dependence (EPARD):
- Clinical Close Coordination (3C) gathering around the general practitioner, the nurse, the pharmacist, and possibly the physiotherapist, specifically trained.
- Territorial Coordination of Support (TCS) in a wider territory.
The improvement of the health pathway also requires the implementation of a shared information system: directory of the sanitary, medical and social resources, and secure messaging.
The health settings will have to implement means and organizations contributing to improve city/hospital relations, and to reduce the rate de early re-hospitalization (early diagnosis of frailty, anticipations of discharge conditions, assessment of medical, psychological and social needs inside the PPH); they will have to provide the city actors and nursing homes with their expertise. They will be supported by a “committee of geriatric coordination”.