Traditional health and social care models are not attuned to the complex and changing needs of a population that is ageing, living with multiple physical and mental health conditions, functional and cognitive impairment, frailty or disability.
Frailty and multimorbidity are complementary concepts associated with greater clinical complexity, increased use of healthcare resources and higher costs. In a cross sectional observational study of healthcare utilisation by 2598 older people in Germany, (Bock et al., 2016) reported that frailty phenotype (>3 Fried criteria) increased total healthcare costs by 680 euro over three months when controlled for comorbidity and ageing.
Harrison et al., (2015) consider that frailty shares many features of a chronic condition: a dynamic syndrome that cannot be cured but may be prevented and better managed in primary care through an interdisciplinary chronic disease management approach that anticipates and proactively manages episodes of deteriorating function. Interventions common to both multimorbidity and frailty include proactive assessment, care planning and review; coordination of care; targeted enablement and support for self management; and behaviour change approaches that go beyond the scope of a traditional biomedical approach.
Integrated care has emerged as an effective way to improve outcomes for people with chronic and complex care and support needs. Many chronic care programmes aim to deliver integrated care through continuous relationships with a primary care or social care professional, supported by coordinated care from an interdisciplinary team. It is widely suggested that integrated care may be most effective when applied to an older population, but there is limited data from cost-effectiveness studies to support this hypothesis.
Objectives:
We considered established models of integrated care for chronic disease to understand their contribution to the prevention and management of frailty.
We explored the following questions:
1. What are the core concepts within models of integrated care?
2. What is the experience of implementing models of integrated care for frailty?
3. What are the outcomes from adopting integrated care models for people who are frail?
4. What are the implications for future research and education on integrated care for frailty?
Scope:
The review had a specific focus on models of integrated care and support to address frailty in primary care and community settings. However this report also considers evidence for the effectiveness of models of care for frailty in hospital and at the interface between hospital and community.
METHODS
A systematic search of peer-reviewed medical literature published from 2002 to 2017 was undertaken to identify articles assessing the impact of models of care to prevent or manage frailty. The search was conducted in Medline via PubMed by combining two key concepts: a frailty approach and models of care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used.
Search terms frailty or frail were applied without prejudice as to the specific definition. As frailty is a complex syndrome that requires a response across a continuum or “whole system” of care, the following search terms were used: model(s) of care; care model(s); integrated care; health and social care; managed care; coordinated care; and comprehensive care.
As prevention of frailty is particularly influenced by interventions delivered in primary care and community settings, a second query used primary care, community care, community based care, community dwelling and care, home based care, & home care. The specific query translation is included in Annex 1.
Peer-reviewed literature
As a first search of titles and abstracts identified 1065 potential articles other databases were not searched. A more filtered review of titles identified 157 abstracts (42 from the first query and 115 from the second). No completed systematic reviews on preventing or managing frailty in the community were registered in the PROSPERO database or Cochrane library.
Systematic reviews on Comprehensive Geriatric Assessment and Intermediate care models were analysed and their references tracked to complete the report as illustrated in Figure 1. After applying exclusion criteria (focused on a specific disease or intervention without considering service delivery, or lack of data on impact), 43 articles were analysed using a standard template to capture information on frailty definition and assessment, and the scope, setting and type of interventions.