Embrace,: a model for integrated elderly care

Introduction: Societies worldwide are challenged by the ongoing growth in health care expenditures and changing patterns in demand for health care, especially regarding long-term care. Integrated care models promise to provide a solution to control these challenges. The Chronic Care Model (CCM) offers an evidence-based framework for this. To arrange a suitable level of care, the CCM can be combined with the Kaiser Permanente Triangle, a population management model. Embrace was based on these two models and is a population-based integrated care model for all community-living elderly people of 75 years and older. Practice: Based on the results of the annual screening, elderly people will be assigned to one of three risk profiles with corresponding care intensity levels (Robust, Frail and Complex care needs). Next, a multi-disciplinary Elderly Care Team (ECT) provides personalized, pro-active and preventive care and support. All elderly people are offered a self-management support and prevention program. Regarding elderly people in the Robust profile, attention is paid to participation in society, combined with education programs on preserving one’s health. Frail elderly people and elderly people with complex care needs are regularly visited by their case manager, a social worker and a district nurse, respectively. During the first home visit, the case manager administers a history questionnaire to identify (potential) problems. Next, a care and support plan is formulated in accordance with the clients’ needs and wishes. The plan is put into practice after consultation with the ECT. During subsequent visits, the case manager and the client discuss the situation and the progress of the care and support plan. The progress and effectiveness of the interventions is monthly discussed by the ECT. Research methods: The effectiveness of Embrace is being studied by means of a stratified randomized controlled trial (RCT) with balanced allocation of elderly participants to care as usual or Embrace. Patients from participating general practitioners, aged 75 years and older, and living at home or in a home for the elderly, were eligible for inclusion. The intervention lasts twelve months. Health outcomes for elderly people and their caregivers, as well as effects on quality of care, service use, and costs will be examined. Qualitative research will be conducted to determine patient and professional experiences with Embrace. Results and conclusion: Since January 2012, Embrace is put into practice in fifteen general practitioner practices in the province of Groningen, the Netherlands. In total,1,474 elderly people are participating. The qualitative study among elderly participants indicated that, due to regular attention, participants feel safe and secure and have the confidence to remain living at home. The qualitative study among case managers indicated that, due to the structural and continuous contacts with their clients, case managers identify problems early, take preventive actions and are more competent to meet the needs of their clients. Based on the business case, including all care and support costs related to the target population, it is expected that Embrace reduces service use and costs. Preliminary results of the RCT are expected in the beginning of 2014