Appropriate care paths for frail elderly patients: a comprehensive model

ended

Ageing problems are a common challenge for Europe and health systems: higher frail population in need of long term care, chronic conditions requiring complex response from a wide range of health professionals, often characterized by fragmented and not appropriated care. +65 patients access to ER more frequently; they stay longer to ER usually ending into ordinary admission, with an increasing risks of hospital-related adverse outcomes. APPCARE project aims at creating a new model for the management of frail elderly people including -standardized application of Comprehensive Geriatric Assessment (CGA) -homogeneous and coordinated care pathway, shared among all the involved care givers, traced by the geriatrician on the basis of CGA and performed through the establishment of a care management program particular hospital admission care path for +75 patients, with short intensive observation period -close link hospital-territorial care -frailty prevention program to demonstrate how an innovative and comprehensive management of complex and co-morbid clinical situations, may maintain patient’s functional status in its clinical trajectory, optimizing health care systems. APPCARE will design the model on the basis of best practices already tested in the involved territories, to evaluate scalability of these existing strategies. Relevance to 3^ Health Progr.: APPCARE model is built up in order to achieve a complete and coordinated standard of care for frail patients, where all the involved caregivers agree and follow a homogeneous care path traced by geriatric specialist. This is perfectly in line with the addressed topic, reflecting the EIPAHA strategic plan. It answers the calls for better cooperation and communication between primary healthcare professionals and geriatric professionals to deal with problems of frailty and comorbidity reduction of unnecessary hospitalization and prevention of the related adverse outcomes early diagnosis and screening for frailty risk facto