Abstract
Background: The increase in cases of dementia and frailty in Ponte da Barca has brought about the need for an integrated approach, with a focus on improving the quality of life of the elderly and supporting their caregivers.
Approach: The IADem Plan is a collaborative initiative resulting from a Cooperation and Partnership Agreement between the Local Health Unit of Alto Minho - Community Care Unit of Ponte da Barca, the Santa Casa da Misericordia of Ponte da Barca and the Psychology Research Centre of the University of Minho, namely the Health and Family Research Group. The IADem Plan is an integrated and innovative intervention based on Personal and Public Involvement (PPI). The Plan identify patients and caregiver’s needs from diagnosis to intervention planning including home visits and personalized care plans, in which patient and caregiver act as active partners in creating personalized support solutions. In addition, a Reference Centre has been set up with diagnostic and training units, which provide training and ongoing support for patients and caregivers in the community.
Results: Individual Interventions and Support for Informal Caregivers
•Population Profile and Diagnosis: Since 2020, the Plan has identified cases of dementia and frailty in 978 elderly people (51.4% of the population over 75), enabling early diagnosis and personalized care.
•Individual Interventions (2023): The team supported 398 patients, providing psychological counselling to 108 people, palliative care to 3 patients, and interventions in areas such as cognitive stimulation (32 patients) and falls prevention (111 patients). These actions were aimed at improving patients' general well-being and preventing complications associated with frailty.
•Dementia Consultation and Multidisciplinary Integration: As part of the pilot project in partnership with ULSAM Neurology, individualized care plans were developed for 65 patients after home visits and diagnoses. Inter-professional collaboration made it possible to signpost and refer 49 patients to other services, such as nutrition and psychiatry.
•Support for informal caregivers: In 2023, 47 informal caregivers took part in training programs and psychological support. Of these, 14 received psychological help, promoting caregivers' mental health and offering strategies for dealing with stress related to care and self-care.
Conclusion: The IADem Plan, based on Pillar 3 of Care Integration: “People as Partners in Health and Care”, highlights the importance of actively integrating patients and caregivers in the planning and implementation of interventions. This approach not only contributes to strengthening interprofessional collaboration, but also to a truly person-centered care approach, where the needs and preferences of patients and caregivers are directly incorporated into clinical practice.
The results of the IADem Plan show that involving patients and caregivers in the process of diagnosis, therapeutic management and compliance with the care plan significantly improved the effectiveness of interventions.
The expansion of home visits is a key element of this model, providing caregivers and health care professionals with a more comprehensive understanding of the patient's condition in their usual environment, enabling a more appropriate and personalized response to their needs.