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Erschienen in: Wiener klinische Wochenschrift 11-12/2019

21.05.2019 | main topic

Pilot study of an integrated care model using the geriatric assessment tool

verfasst von: Ariana Bytyci, Genc Ymerhalili, Thomas Ernst Dorner, Katharina Viktoria Stein, Osman Maxhera

Erschienen in: Wiener klinische Wochenschrift | Ausgabe 11-12/2019

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Summary

Background

Older people with type 2 diabetes mellitus often suffer from adverse medical and social conditions which are often unrecognized in routine care. Integrated care aims to address all these aspects and centers on the needs of the patient and not the disease. The Accessible Quality Healthcare project in Kosovo, is piloting an integrated care model for patients 65 years and over with type 2 diabetes mellitus, which also introduces comprehensive geriatric assessment and care planning.

Methods

In this study two groups (1) a central working group and (2) a multisectoral implementation group of health and social care professionals were established to develop a geriatric assessment form and an individual care plan form for this project.

Results

The groups decided to address the following problems in the geriatric assessment: activities of daily living, urinary incontinence, gait, balance, falls, depression, cognitive function, and frailty. The assessment is carried out by a nurse and a social worker in the living environment of the patient, and the individual care plan is drawn up jointly by a doctor, a nurse, and a social worker and includes (1) problems of the patient, (2) specific goals for each problem and (3) activities to reach the goals.

Conclusion

This intervention is one of the first in the health system in Kosovo to implement integrated care in a very vulnerable population. Physical training will be an important tool to tackle many problems detected through the geriatric assessment and which are also associated with type 2 diabetes mellitus.
Literatur
9.
Zurück zum Zitat Wenger NS, Roth CP, Shekelle PG, Young RT, Solomon DH, Kamberg CJ, Chang JT, Louie R, Higashi T, MacLean CH, Adams J, Min LC, Ransohoff K, Hoffing M, Reuben DB. A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia. J Am Geriatr Soc. 2009;57:547–55.CrossRef Wenger NS, Roth CP, Shekelle PG, Young RT, Solomon DH, Kamberg CJ, Chang JT, Louie R, Higashi T, MacLean CH, Adams J, Min LC, Ransohoff K, Hoffing M, Reuben DB. A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia. J Am Geriatr Soc. 2009;57:547–55.CrossRef
10.
Zurück zum Zitat Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2. Med Care. 2003;41:1284.CrossRef Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2. Med Care. 2003;41:1284.CrossRef
11.
Zurück zum Zitat Siu AL. Screening for dementia and investigating its causes. Ann Intern Med. 1991;115:122–32.CrossRef Siu AL. Screening for dementia and investigating its causes. Ann Intern Med. 1991;115:122–32.CrossRef
12.
Zurück zum Zitat Romero-Ortuno R. The frailty instrument for primary care of the survey of health, ageing and retirement in europe predicts mortality similarly to a frailty index based on comprehensive geriatric assessment. Geriatr Gerontol Int. 2013;13(2):497–504.CrossRef Romero-Ortuno R. The frailty instrument for primary care of the survey of health, ageing and retirement in europe predicts mortality similarly to a frailty index based on comprehensive geriatric assessment. Geriatr Gerontol Int. 2013;13(2):497–504.CrossRef
13.
Zurück zum Zitat Leichsenring K. Developing integrated health and social care services for older persons in Europe. Int J Integr Care. 2003;4:1568–4156. Leichsenring K. Developing integrated health and social care services for older persons in Europe. Int J Integr Care. 2003;4:1568–4156.
14.
Zurück zum Zitat Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, Ricketts GD. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623–33.CrossRef Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, Ricketts GD. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623–33.CrossRef
Metadaten
Titel
Pilot study of an integrated care model using the geriatric assessment tool
verfasst von
Ariana Bytyci
Genc Ymerhalili
Thomas Ernst Dorner
Katharina Viktoria Stein
Osman Maxhera
Publikationsdatum
21.05.2019
Verlag
Springer Vienna
Erschienen in
Wiener klinische Wochenschrift / Ausgabe 11-12/2019
Print ISSN: 0043-5325
Elektronische ISSN: 1613-7671
DOI
https://doi.org/10.1007/s00508-019-1512-7

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