It took the Covid to remind us that with almost 14 million over-65s (of which 5 and a half million suffering from at least three chronic diseases and 4 million with severe disabilities), multimorbidity and frailty are the real challenge for the country.
“The Covid it was a natural stress-test of our health system, which showed the fragility in the area and a certain resilience within the hospital – comments Professor Roberto Bernabei, President of Italia Longeva and member of the technical-scientific committee. – We have been talking about territorial medicine for some time, now the time has come to equip primary care with concrete tools and clear organizational guidelines, and the resources arriving from Europe are an opportunity not to be wasted ”.
Health experts are therefore aiming at two primary goals now. The reorganization and strengthening of the offer of local services, starting with home care and the use of standardized assessment tools to recognize, measure and treat frailty.
During the fifth edition of the “States General of long-term care”, The two days (this year in virtual form) of in-depth analysis on Long-Term Care organized by Long-lived Italy, two important innovations on this issue were illustrated. Lindex of frailty in General Medicine and theSynthetic indicator of adherence (closely related to the phenomenon of polytherapy – 14% of the elderly take 10 or more drugs per day).
“Today the great urgency, and investment priority, is to put the health system in a position to take care of the greatest number of elderly people at home – explained Professor Bernabei. – But home care is not something that is improvised, you need to know how to do it, have articulated skills, ability to assess needs and intervene on the patient. And it requires precise and standardized technologies, tools for assessing needs. The priority is first of all to define who does it and how it is done. We use the resources of the Recovery Fund to build an efficient and modern home care model, so as not to be caught unprepared when the next pandemic, a heat wave or any other type of emergency with an impact on frailties arrives ”.
Territorial assistance
To understand that long-term care, territorial assistance, has not held up in the face of the pandemic, just look at the offer of home care (ADI) and assisted residential care (RSA), which in 2019 remained almost unchanged compared to the previous year. Lack of assistance, in the face of an increase in informal assistance, ie by non-professional caregivers, which in Italy is carried out for about 70% by immigrants.
According to the data of Ministry of Health, in 2019 2.4% of over-65s were assisted in RSA (329 thousand people, 91% over 75) and 2.8 elderly out of 100 (378 thousand people) received home care, less than one third compared to the European values which are around 8-10%, and with strong regional differences. More comforting is the picture relating to the offer of palliative care to cancer patients. In 2019, about 50 thousand patients benefited (29.7% of the total), who were assisted by the palliative care network at home or in hospice (+ 5.3% compared to 2017).
The identikit of every fragile patient
If the goal is to deal with the complexity and not the single pathology, then the priority is to be able to trace the identikit of each fragile multi-soft patient. The good news – as reported in the monothematic study on “multimorbidity and frailty” contained in the Long-lived Italy – is that family doctors will be able to use a tool to measure the frailty of their patients, developed by the Italian Society of General Medicine, in collaboration with Italia Longeva and with the Karolinska Institutet of Stockholm.
“Now, it has to be organized a care chain for taking charge of the elderly centered on the measurement of frailty – comments the President again Bernabei – by the general practitioner, who must evaluate the level of fragility of his clients; by the hospital which, since the arrival in First aid, must frame the patient’s level of fragility to facilitate the proper functioning of the continuity of care machine at the time of discharge. Again, knowing the distribution offrailty index of residents of a nursing home it can help to estimate in advance the care burden required and the resources to be deployed. The computerization of these assessments and their accessibility are an essential element to improve processes and to achieve quality long-term care “.
If from the point of view of assistance it is important to rethink some sectors of the health system that have proved ‘fragile’ with the pandemic, starting with the RSAs, to improve the governance of long-term care it is necessary to give an effective and sustainable response to theme of (lack of) adherence to therapy, closely related to the increase in multimorbidity and polytherapy (the use of 5 or more drugs), which entails a greater risk for patients of complications and hospitalizations, and a significant increase in healthcare costs.
The proposal of Long-lived Italy a synthetic indicator of adherence, to be included among the indicators monitored in the New Lea Guarantee System, as a standardized strategy for measuring adherence across the country. To date, in fact, the issue of adherence is absent among the criteria to be respected to ensure compliance with the Essential Levels of Care (Lea), thus missing a mechanism that incentives the Regions and the Health Authorities to implement targeted interventions to promote greater adherence, a determining factor for achieving better health outcomes in the population and reducing the costs borne by the NHS.
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