Abstract
The meeting of the European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) action group A3 together with members of the Reference site collaborative network (RSCN) in December 2019 in Rome focused on integration of evidence-based approaches on health and care delivery for older citizens at different levels of needs with expertise coming from stakeholder across Europe. It was the final aim of the group to co-create culturally sensitive pathways and facilitate co-ownership for further implementation of the pathways in different care systems across Europe.The study design is a mixed method approach. Based on data analysis from a cohort of community-dwelling over-65 citizens in the framework of a longitudinal observational study in Rome, which included health, social and functional capacity data, three personas profiles were developed: the pre-frail, the frail and the very frail personas. Based on these data, experts were asked to co-create care pathways due to evidence and eminence during a workshop and included into a final report.All working groups agreed on a common understanding that integration of care means person-centered integration of health and social care, longitudinally provided across primary and secondary health care including citizens’ individual social, economic and human resources.Elements for consideration during care for pre-frail people are loneliness and social isolation, which, lead to limitation of physical autonomy in the light of reduced access to social support. Frail people need adaption of environmental structures and, again, social resource allocation to maintain at home. Very frail are generally vulnerable patients with complex needs. Most of them remain at home because of a strong individual social support and integrated health care delivery.The approach described in this publication may represent a first approach to scaling-up care delivery in a person-centered approach.
Highlights
The understanding of health as a social continuum over the whole life span requires complex interactions within health and care systems to facilitate health and wellbeing for as many citizens as possible 1
The aim of the 2019 winter meeting held in Rome by the European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) - A3 action group and the reference sites collaborative network (RSCN) of the EIPonAHA was to prioritize the multidimensional assessment of frailty as the starting point for building up specific needs’ profiles of older citizens in primary and community care and to facilitate future health and social care scaling-up actions within the reference sites of the RSCN
Detailed analysis data are shown in the supplementary material of this article. 42.6 % were detected as “robust”, 36.1% as “pre-frail”, 13.6% as frail and 7.9% as “very frail” according to criteria of selection outlined in the method section (2.1.)
Summary
The understanding of health as a social continuum over the whole life span requires complex interactions within health and care systems to facilitate health and wellbeing for as many citizens as possible 1. An innovative response to individual citizens’ needs requires the implementation of actions at individual, population and system level, that demands political leadership and stronger commitment of authorities making use of information and communication technologies 2. To enable this “transformation” it seems mandatory to evaluate the needs of citizens according to disease and functional capacities and to give access to this information to a broader audience 3. The aim of the 2019 winter meeting held in Rome by the European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) - A3 action group and the reference sites collaborative network (RSCN) of the EIPonAHA was to prioritize the multidimensional assessment of frailty as the starting point for building up specific needs’ profiles of older citizens in primary and community care and to facilitate future health and social care scaling-up actions within the reference sites of the RSCN
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