Abstract
Background: Enabling older adults to engage with and participate in their care planning requires specific geriatrician input to overcome the complex challenges facing frail patients in the community setting. Planning for future events is an integral component of the evolving collaboration between the older person, those closest to them and members of a multi-disciplinary team.
Methods: I conducted a literature review using key terms on PubMed. I also reviewed the World Health Organisation’s (WHO) Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care1, as well as reviewing the guidelines and framework for the Irish National Integrated Care Programme for Older persons2. Observing and participating in complex cases in an ambulatory community setting showed the practical considerations involved in complex case management.
Discussion: While standardised care pathways have always been a solution for ensuring patient safety, improving risk-adjusted patient outcomes, increasing patient satisfaction and optimising scarce resources, studies have shown that standardised care pathways are more effective in contexts with predictable care trajectories and low uncertainty and complexity3. A person-centred care plan engages older persons as stakeholders in their own care.
Adopting the WHO’s ICOPE framework requires assessment of intrinsic capacity and promptly diagnosing and managing losses, both functional and cognitive. Early identification of complex cases involving multi-morbidity, polypharmacy and advancing frailty allows an integrated care team to pool expertise and facilitate patient autonomy in the decision-making process.
Specific ambulatory community geriatrician hubs within Community Healthcare Organisations (CHO) enables complex cases to be individually managed in conjunction with a multi-disciplinary team. Identifying unrecognised or unvoiced needs and taking proactive steps to plan for preventative, personalised care is a key component of a multi-modal service.
Conclusion: A shift towards an integrated, people-centred approach demands increased community level interventions with coordinated services, such as screening, assessment and management. On personal reflection, it appears that the majority of older persons linked in with an ambulatory hub benefit hugely from specialist MDT input.
However, a subsection of older persons in the community need more in-depth specialist support, highlighting the need for increased support in an integrated care model. Establishing the concept of shared care requires transfer of information and knowledge pooling. There is undoubtedly a gap for complex case discussion in the community. A solution to this could include virtual case conferences, facilitating collaboration and coordination between services that provide community led support to older persons and other service providers. Further strengthening of pathways and systems to ensure care plan suitability requires reciprocal buy-in from tertiary centres.