Most older persons prefer to age in their homes and communities. However, as frailty and comorbidities increase with age, care is often not delivered in a personalized way that facilities ageing in place. Fragmentation of services across care settings make it harder for older persons to access help in a timely manner, particularly those with complex needs and little social support.
In these situations, older persons have limited choices and control over the way their care is planned and delivered. Promoting integrated and personalized care by joining up services and encouraging providers to deliver care in a way that matter to them is key to improving holistic health outcomes and quality of care for older persons.
- Engage older persons to identify and discuss problems related to their condition and jointly develop a care plan. Conduct goal setting where older persons can set priorities for their care and desired outcomes. Such an approach is particularly suitable for management of long-term conditions.
- Train staff in healthcare or social care agencies on the skills and mindset required to deliver personalized care. Professionals need to be adequately prepared to work jointly and acquire new skills and behaviors such as motivational interviewing and patient activation. See Case Study 3.4a on how networks to promote personalized care was initiated in the central region of Singapore.
In partnership with the SingHealth Regional Health System, the National Healthcare Group in the central region of Singapore launched the ESTHER network to promote the philosophy of person-centred care and train a pipeline of ESTHER Coaches to drive improvement work to better serve our patients and their caregivers. Participants are mostly staff from health and social care agencies in the community, or patient advocates. After training, participants are expected to initiate quality improvement projects to promote personalized care and eventually incorporate these into the work processes of their organization.
- Establish community health teams composed of multidisciplinary healthcare professionals from hospital and community partner and provide platforms for these teams to meet, identify service gaps, and areas of collaboration from improving co-management workflows to data-sharing for care continuity. See Case Study 3.4b on how such a network was developed organically in the central part of Singapore, where Whampoa is located.
- Adopt population-health approaches to assess and stratify older persons with different profiles of needs to different services, see Case Study 3.4c for the national approach for risk stratification of older persons in Thailand.
- Care coordination of specialist care, primary and community care is particularly important for older persons with complex needs. To promote integration, promote use of a consistent set of assessment tools and conduct multidisciplinary team meetings to plan the care of older persons in a holistic personalized way.
Whampoa is one of the seven subzones of the Central Regional Health System in Singapore. The Regional Health System was set up to strengthen partnerships across care settings. Each Regional Health System is anchored by a public hospital working closely with community hospitals, nursing homes, home care and day rehabilitation providers, polyclinics as well as private General Practitioners (GPs) within the region. The central health system has formed multidisciplinary teams within community facilities, compromising of doctors, nurses, and allied health professionals from the hospital. The aim is for this team to work with service providers in each subzone to coordinate care and support their needs.
Thailand has developed a national system that mobilizes the community sector to deliver long-term care of older adults. Part of the system involves conducting population-based screening of older persons and stratifying them into four profiles of needs. Referral to programs and service are guided by their profile of needs. The long-term care system is financed using a capitated payment model, where the National Health Security Office allocates a fixed amount of budget for each person to the local government, based on anticipated service usage for each profile.
- Social prescribing is a part of personalized care provided by a range of community-based non-clinical organizations to people who need support for their physical or mental health through social interventions. The referrals for community services mostly come from healthcare professionals, including general practitioners, nurses, and other healthcare workers. This can be through connecting older persons to a ‘care navigator’ or community worker to help them access the available range of social services.
- Provide training for people with long-term conditions to develop the knowledge, skills, and confidence to manage their own health effectively. See Case Study 3.4d on the SCOPE program in Singapore that boost the self-efficacy of older persons to manage their conditions and health.
- Develop peer support to support the long-term care of older persons. For example, train peers with similar health experiences to form support groups and link older persons to mutual aid groups, see Good Practice 2.3 on catalyzing networks and platforms for mutual aid.
The Self Care on Health of Older Persons in Singapore (Project SCOPE) is a community development programme that aims to improve the health and wellbeing of well and mildly disabled older persons aged 55 years and above. Participants undergo up to 6 months of psychoeducation on different aspects of chronic disease management, as well as general knowledge on health promotion. They also form peer support group which are sustained after the programme ends, to monitor each other’s health. Funded by the Ministry of Health and the Ministry of Education, preliminary evaluation of the pilot program has demonstrated effectiveness of the program in increasing self-care of older participants.
Integrated and personalized care provides a uniform way for older persons to access programs and care in a more coordinated way that matters to them. Evidence indicates that shared decision making, and patient activation increase the Sense of Control (IC4) and confidence of older persons in expected outcomes of their care, improves health outcomes and reduce costs due to non-compliance. Delivering personalised care requires a whole-system approach, integrating services around the person including health, social care, public health, and wider services that strengthens Organizational Networks and Partnerships (CC12). Beyond physical care, the focus on social prescribing recognizes the contribution of communities and the social sector to promote health, address social determinants of health, and build resilience of older persons.
- Integrated personalized care requires timely information sharing. Personal care records need to be readily shared across the multidisciplinary team and care providers, with standardized documentation practices.
- Facilitating these areas of integration require strong Organizational Networks and Partnership (CC12) and mutual commitment to solving system barriers.
- Encourage providers to collaborate through collective funding and quality standards. Community-wide health improvement plans and quality standards by service providers should be created based on the vision, mission, goals of this network and in response to the various risk profiles of older persons in the zone. Capitated payment is one funding model that incentivizes collaboration as it shifts the responsibility for controlling total cost of care from payers to providers in the network.
from javascript
from javascript