Contemporary care model for older people: an urgent need

Abstract

In this article, a proposed solution is developed for a resolutive care model with an excellent cost-benefit ratio, congruent with the latest solutions in integrated care for the older population. The theory and concepts underlying the proposed model are outlined in detail, together with the epidemiological assessment instruments used. The article provides the context behind the global growth of the older population and, more specifically for Brazil, showing the social and financial impacts of this shift on society. Drawing on this analysis, we advocate that care provision for the older population be rethought, with greater priority given to disease prevention and health promotion actions. We also propose judicious use of technology for consultations, monitoring and preventive strategies, and for coordinating new care approaches. We believe the emphasis on care for the older population should take a low-complexity approach to reduce wastefulness, ensure rational use of health system resources, and make optimal use of the professionals involved.

Keywords
Older people; Care Model; Prevention; Health Promotion

Resumo

Proposta de um modelo assistencial resolutivo e com excelente relação custo-benefício, em linha com o que há de mais contemporâneo no cuidado integral para o grupo etário dos idosos. Apresentou-se em detalhes a teoria e os conceitos que fundamentam o modelo proposto, bem como os instrumentos de avaliação epidemiológica utilizados. O artigo contextualiza o crescimento desse contingente populacional no mundo e, em particular, no Brasil, mostrando seus impactos sociais e financeiros para a sociedade. A partir dessa análise, defende-se que o cuidado prestado à população idosa seja repensado, valorizando cada vez mais as ações de prevenção de agravos e de promoção da saúde. Propõe-se também o uso inteligente da tecnologia para consultas, monitoramento, atitudes preventivas e na coordenação dos novos cuidados. Acredita-se que a ênfase da atenção ao público idoso deve se dar nas instâncias leves de cuidado, de forma a minimizar desperdícios, usando com racionalidade os recursos disponíveis no sistema de saúde e valorizando os profissionais envolvidos.

Palavras-Chave:
Idosos; Modelo Assistencial; Prevenção; Promoção de Saúde

INTRODUCTION

The increase in life expectancy of the Brazilian population represents a major stride. Live longer – grow old – this has become a reality in the last few decades and is set to increase further in the years to come. However, making the most of these extra years with functional capacity, health and quality of life, should also be an integral part of this advance. Researchers have been in search of a new model for health service delivery. Such reforms are both necessary and feasible.

The health care of the older population can be restructured in the sector toward providing better care outcomes at a lower cost. For this shift to come about, all actors in the sector must take a lead in achieving the necessary changes and be open to innovation by returning to simpler care practices and recovering values lost amid the current national health system.

Based on this premise, the present article has been structured along complementary lines. The statistics describing the older population are first presented, an age group which, proportionally, is now the fastest growing worldwide. This demographic transition process is examined, with an emphasis on collective health. The care model for older people is the outlined, together with all its specificities, taking into account gains in life expectancy.

Nowadays, it is not uncommon for people to live into their 80s, 90s or beyond. However, there are major concerns about the current care model in place, since these additional years of life should not be marked by suffering, pain and high costs.

Integrating the knowledge, theory, application of instruments and routines, is paramount for this care approach to gain traction in Brazil and for both public and private health sectors to improve the service provided to this growing age group. Unless changes are made to the care model for the older population, the prospects in the years ahead look bleak.

The objective of the present study is to put forward a quality innovative care model. The prevailing, outdated system, will only serve to exacerbate the already poor service and health crisis, particularly for older users, the group associated with the greatest demand and cost on the system. Efforts should be made amid an urgent need for change, as furthered by the present proposal, paving the way for more adequate health care for the older population.

Demographic transition

All of the demographic projections made in the 1980s regarding growth in the older population have proven accurate. Misses, if any, have occurred in the form of underestimates¹-³.

Population ageing is one of humanity’s greatest triumphs. Surviving into old age was once a rare privilege, but is now the norm in Brazil and many developing countries. There has been a substantial improvement in the health parameters of the population, yet this triumph presents its own challenge: caring for this age group and conferring quality to the extra years of life.

In 2002, the World Health Organization (WHO) released a publication with a policy framework for active aging, defined as the process of optimizing opportunities for health, participation and security to enhance quality of life as people age.⁴ This new paradigm requires action involving 3 basic pillars: health, participation and security⁵-⁶.

In essence, the health pillar goes beyond the strictly physical realm to also encompass mental and social well being, all recommended targets of intervention at the level of public policies and programs. The word “active”, however, refers to continuing participation in social, economic, cultural, as well as in community and civic affairs, not just the ability to participate in the labour force. Lastly, security defines the existence of some system of social protection that ensures an adequate level of socioeconomic security, without which it would not be possible to guarantee health nor the participation of older people.

In addition to the importance of public policies, there is also a very clear message of individual responsibility of the older population themselves, who should seek to stay active and make efforts to safeguard their health, participation and security ⁵. As this concept has gained traction in the political sphere, official publications addressing this have becoming increasingly centred on the economic imperative: that of keeping older individuals engaged in productive activities⁶.

In Brazil, the shift in age structure with the growth in the third-age segment is a relatively recent phenomenon. The growth rate of the Brazilian population has been high over the last 70 years. Equally, the increase in the older population has also been significant by global standards.

Currently, there is large contingent of children, adults and older people. From 2030, however, there will be a reduction in the number of younger individuals and in the overall population, a trend evident in the preliminary data from the most recent Brazilian demographic census. Exceptionally, the census was conducted in 2022, owing to the COVID-19 pandemic. Initial results show a decline in the Brazilian population, a pattern replicated in other countries. China, for example, is set to see a shrink in its population, which declined for the first time in over 60 years and whose total will soon be exceeded by the population of India. In December, according to the National Office of Statistics, China had 1.41 billion inhabitants. During 2022, there were 9.56 million births, 850,000 fewer than the 10.41 million deaths recorded. This demographic pullback was expected to take place only in 2031, according to United Nations predictions.

This earlier decline, by almost a decade, in the population did not happen by chance. Akin to other countries, women have opted to put their careers ahead of maternity and encounter less social resistance in a society already used to smaller families.

The demographic statistics show that the economy will be able to rely increasingly less on young cheaper labour, a key factor in China´s economic ascension, as the country exported larger volumes of consumer goods and manufactured products.

The Chinese example serves as a warning to Brazil where, as mentioned above, the 2022 consensus suggests lower-than-predicted population growth, signalling that the demographic bonus period — with younger individuals outnumbering older people in the population — has come to an end earlier than expected. Mirroring China, Brazil will become aged before becoming rich — and will only be able to sustain solid growth rates if the productivity of the economy can be raised.

Taken together, these data indicate that the future of the 21st century will be a grey one, i.e., the percentage of older people will reach levels never before seen in history. The Brazilian case is no different, but the process of population aging is even stronger, with the proportion of older people exceeding the global average. From a demographic standpoint, this is a crucial issue, since the high-income countries underwent more gradual growth over the course of the 20th century and, with their economic power, had more time to offer this contingent of the population better structure and resources.

Brazil needs to embrace the goal of ensuring quality of life for its older population which, like the vast majority of the general population, have low educational level and scant social protection. In terms of health, the older population suffers from multiple chronic non-communicable diseases (NCDs)⁷, which need constant monitoring and permanent care⁸, with growing demand representing an economic burden for society⁹. Hospital admissions of older patients are more frequent, and length of stay longer, compared to other age groups. This scenario has huge economic, pension and social implications.

Human aging should not be regarded as a burden. Social policies must be devised for this group. In the health field, care should be managed in a more contemporary and adequate way to safeguard this wealth of knowledge and experience without this becoming overly costly for the sector.

In a recent projection, the IBGE (Brazilian Institute of Geography and Statistics) estimated the Brazilian population at 207.8 million, lower than the result expected for the Census (215 million). If the Census confirms this figure, the demographic bonus in the form of a higher proportion of population of economically active age (15-65 years) will have petered out between 2018 and 2021. With a larger proportion of older people, the Brazilian population is set to stabilize by around 2047 or earlier. Government figures and public managers should no longer, therefore, cultivate the image of Brazil as a “young nation” with a plentiful supply of labour. Aging is accompanied by countless challenges. The availability of young workers in the labour force can no longer be taken for granted. More will need to be produced by fewer workers. In economic terms this translates to one word: productivity.

A decrease in the number of young people in the population can be seen in primary education enrolment figures, which are falling at the rate of 400,000 a year. Brazil has made mixed progress in implementing consistent improvement in the primary education system. Efforts to raise the standard of education and training have not translated to innovation, productivity or wealth generation, elements required for the country to develop. In parallel, older workers need to be requalified, promoting “digital literacy” so they may also continue working.

As in Europe, fewer schools should be built, given the government will have to provide support for networks of caregivers of older people, with increasingly heavy burden on the Pensions and Social Security system. These are not far-fetched daydreams of some distant future. This issue should already have been addressed by previous governments.

The incumbent government, more in tune with the globalized world, must keep in step with this important shift in demographics and its social consequences.

The magnitude of population aging in Brazil is depicted by Figure 1.

Figure 1
Life expectancy and birth rates of Brazilian population from 1940 to 2020.

It is important to highlight the huge demographic impact these data illustrate.

Chronic disease and care model

In Brazil, the leading cause of mortality and morbidity are chronic non-communicable diseases (NCDs), which typically develop slowly over long periods and have difficult-to-predict long-term effects. Neuropsychiatric disorders account for a large proportion of these NCDs¹⁰.

In a 2015 report, the WHO noted that, of the 38 million lives lost in 2012 due to NCDs, 16 million (42%) were premature and avoidable¹¹. As the costs of managing these disease mounts worldwide, they account for an increasing chunk of public and private expenditures¹².

Chronic conditions traditionally include cardiovascular diseases, diabetes, asthma, chronic obstructive pulmonary diseases (COPD) and chronic degenerative diseases. With improved survival rates, this group of diseases now also includes many types of cancer, HIV/AIDS, neuropsychological disorders (such as depression, schizophrenia and dementia), arthroses and visual/auditory deficits. Most of these conditions have no cure but many can be prevented or controlled through early detection, by adopting healthy habits and diet, engaging in regular exercise, and accessing adequate timely treatment.

In addition, many of these chronic diseases constitute a set of conditions, where some authors and institutions define individuals with multiple co-occurring conditions as complex patients, characterized by a profile of chronic presentation. The most prevalent features differentiating this group include the presence of several concomitant chronic diseases, high use of urgent hospital services with several episodes during the same given year, temporary or permanent reduction in personal autonomy, and polypharmacy. There may also be other associated factors, such as advanced age, living alone or with low family support and fall episodes, among others¹³.

Various chronic conditions are linked to an aging society, but also to life-style choices, such as smoking, alcohol use, sexual behaviour, poor diet and low physical activity (sedentarism), besides genetic predisposition. The common feature these conditions share is the need for a complex long-term response coordinated by health professionals from a range of disciplines, with access to the required medications and equipment, as well as strategies to encourage patient adherence to treatment and also social welfare. However, most health care and services are still geared up for dealing with acute episodes. Against this backdrop, the management of chronic diseases is increasingly regarded as an important issue by managers and researchers worldwide who seek interventions and strategies to tackle these conditions. It is important to emphasize that improvements in the quality of life of the population are derived from a series of factors, including the technological advance seen in many fields of knowledge and in modern science.

Imperative for change

The demographic transition and improvement in social and economic indicators in Brazil relative to past decades, has led to a growth in the contingent of older individuals and increase in the financial pressure on public and private health systems. Growth in this population group is accompanied by an increase in burden of chronic diseases and greater health expenditure¹⁴. This growing demand for health services can lead to a shortage and/or constraint of resources.

Nevertheless, most public health problems impacting the population are preventable, whether communicable or non-communicable diseases. This statement is borne out by the significant decline in mortality from cardiovascular and cerebrovascular diseases, the fall in incidence and deaths related to cervical cancer, and also the decrease in the prevalence of tobacco use and rates of lung cancer in men¹⁵.

A shortcoming of most care models is their overwhelming focus on the disease itself. Regrettably, preventive action is still viewed as an overload of procedures and additional costs. However, prevention should be seen as a strategy which, over the medium-to-long term, can lower admissions and avoid much higher cost procedures¹⁶.

All evidence suggests that health systems based on biomedicine will run into sustainability problems. This conclusion suggests that programs directed toward the older population should be based on integrated care, led by the health professional and their team, and centred on managing the individual as opposed to the disease, making judicious use of the available technology, supported by quality information and regular follow-up and monitoring. Specialists, hospitals, drugs, and clinical and imaging exams are all important elements of an ideal health model, but the focus should centre on low intensity levels of care with the client treated directly by their doctor¹⁷.

A contemporary health model for the older population should incorporate a flow of actions related to education, prevention of avoidable diseases, delaying the onset of illnesses, early care intervention and rehabilitation of existing conditions¹⁸. In other words, a line of care for older people which strives for effectiveness and efficacy must be underpinned by a coordinated network that incorporates an information system designed with this logic in mind.

Why the discourse-practice gap?

Before describing the proposed care model, a key question must first be addressed. There is a consensus: when probed, all involved, without exception, state they are in favour of this new line of care. This makes it hard to explain why most health managers practice the exact opposite to what they advocate.

The care model for older adults, when properly implemented, is an exception. In the seminal study by the National Health Agency (ANS), headed by Dr. Martha Oliveira in 2018¹⁹, this gap between discourse and practice is exposed.

The time for novelty and oft repeated cliches acknowledged by all (even those who do not heed them) is over. It is laudable to cite the theoretical frameworks or policies aimed at promoting healthy aging, i.e., maintain functional capacity and autonomy, together with quality of life, in line with the principles and guidelines of the Unified Health System (SUS), whose focus is disease prevention. Important national and international health agencies have advocated this concept for many years¹¹,¹³. But the next step forward needs to be taken²⁰.

Thus, we pose the following question: if everyone is discussing this topic and the solutions have already been drawn up, then why has the situation remained unchanged? Why has the theory not been translated into routine practice? Why do leaders and manager not promote change?

In order for the health sector – particularly the geriatric segment – to undergo this restructuring, a point to be considered is distrust. Today´s society distrusts new offerings. Amid this sentiment, any proposal for change is met with scepticism and reluctance. Any established system that is multifactorial and built over many years is hard to change. Bringing about changes in culture is by no means straightforward.

Another bottleneck is care quality, which is still undervalued. This is of huge importance and calls for greatest awareness of health professional and civic society. Some claim that applying instruments to gauge service quality and introducing accreditations and certifications would prove too costly, but qualified services are more cost-effective, less wasteful and have better care outcomes for patients.

Another point is there is now a general understanding that care for older people extends beyond health. Besides diagnosis and prescription, there are other elements important for maintaining functioning, such as social participation, physical activities and mental activities. But a major obstacle remains, particularly within private health, in embracing social actions as an integral part of care. There is a tendency to separate “social” from “curative” actions.

And concerning the model of remuneration of health professionals? This group is generally underpaid, so why not adopt performance-related pay? Associating the discussion of care outcomes with the form of remuneration is a powerful tool incentivizing doing the right thing. Thus, pay for performance (P4P) or performance-related pay (PRP) have become synonymous for the struggle to align access with care quality. Change in the remuneration model based on this new care framework, focusing on results and not volume, needs to be a win-win type model, in which all involved benefit, particularly the patients.

In order to put into practice all of the actions needed for healthy aging with quality of life, care for the older population needs to be rethought and redesigned, with an emphasis on the older person and their particularities. This will result in benefits, quality and sustainability, not only for the older population, but for the Brazilian health system as a whole⁷,²¹.

Thus, concerted efforts are required to transform theory into a care model offering quality for all, including older people. It is an undesirable situation for the SUS to fragment or for there to be an increase in bankruptcies of private healthcare companies.

However, for every year that goes by, the cost of health increases and the quality of care declines. Such a system is unsustainable. It is high time, therefore, to put into practice what all advocate but fail to implement.

Aging and health

Health can be defined as a measure of individual capacity to realize aspiration and satisfy needs, irrespective of age or the presence of diseases⁷. Thus, the need for an efficient cost-effective comprehensive geriatric assessment has become increasingly pressing. The goals of this evaluation are to enable early diagnosis of health problems and to plan support services wherever and whenever needed to keep individuals in their homes and out of institutions. Traditional history taking, physical check-up and differential diagnosis are insufficient to provide a comprehensive evaluation of the range of functions needed for daily living of older individuals²².

In the book entitled ““Repensando a saúde: estratégias para melhorar a qualidade e reduzir os custos” (Rethinking health: strategy for enhancing quality and reducing costs)”²³, the authors hold that health comes before care. In their opinion, the need to measure and minimize risk of disease, offer comprehensive management of diseases, and ensure prevention services for all clients, including those who are healthy, is unclear¹. In this context, the authors state that health should involve preparation for the service that increases the effectiveness of the value chain (set of activities carried out by an organization, such as supplier relations, production/sales cycles and final distribution). This concept was first introduced by Michael Porter in 1985: intervention; recovery; monitoring and management of the clinical condition; guaranteed access; results measurement; and information dissemination.

Health systems comprise several points of care that do not work in an integrated fashion. In general, entry into this uncoordinated network typically occurs when the client is at an advanced stage, where the “front door” tends to be the emergency department of the hospital. This model, besides being inadequate and anachronous, has a dire cost-benefit ratio, since it makes intensive use of highly expensive technology. Its failings, however, should not be blamed on the clients, but on the care model itself, which overloads the higher complexity levels due to a lack of care at primary levels. Home-based care may represent an alternative for some cases. Home care should not be seen as a fad, but as a more modern modality of care¹⁸. However, the advent of the modern hospital is a relatively recent phenomenon in that, not long ago, care was traditionally administered within the home²⁴.

A prospective study of disease management²⁵ offered to beneficiaries of Medicare – a health insurance system for older individuals managed by the North-American government – showed that actions failed to reduce expenses²⁶ and that physicians were unhappy with the insurance providers paying the costs of disease management, possibly reducing their income and interfering in the doctor-patient relationship. Disease management programs for older individuals are even more complex and have a very low cost-benefit ratio, given that treating a disease properly only reduces the rates of morbidity associated with the condition. The best option is to structure models that work in an integrated manner and cater for the whole range of needs²⁷. If this is not the case, then the problem is hard to resolve, because other diseases and their frailties remain. Moreover, resources will not be used rationally²⁸.

Epidemiological information translates to the ability to predict events, allowing early diagnosis (especially for chronic diseases), delaying the onset of these conditions and improving both quality of life and the therapeutic approach. Determining health status of the older population should consider the overall state of health, i.e., take into account a satisfactory level of functional independence, as opposed to merely the absence of disease. Thus, the notion of functioning can be construed as a paradigm for the health of older people, representing one of the most important attributes of human aging, since it encompasses the interaction between physical and psycho-cognitive capacity to perform activities of daily living¹⁸,²⁹.

Well being and functioning go hand in hand. They represent the presence of autonomy, individual decision-making ability and control over one´s actions, establishing and acting on one´s own convictions – and independence – the ability to carry out something by one´s own means –, enabling the individual to take care of themselves and their life. Independence and autonomy, although closely related, are separate concepts²⁹.

Some people are physically dependent but are perfectly capable of deciding on what activities they want to engage in. Others, on the other hand, are physically able to perform certain everyday tasks, but not to choose how, when or where to carry out these activities¹⁸.

Functional evaluation defines the correct stratification and allocation of the older patient into the line of care required, and also allows their care behaviour to be predicted. Functional autonomy is an important predictor of health of older people, but systematically assessing the whole elderly population using long comprehensive scales is far from ideal. A variety of assessment tools is available for screening risk and organizing entry to the health system, validated and translated into Portuguese.

A two-stage approach, dedicating full evaluation only to individuals at high risk, as detected by a process of screening, is more effective and less painstaking. For the first stage of rapid screening, a tool meeting the following criteria should be employed²: simple and safe; short application time and low cost; accurate for detecting the risk investigated; validated for use in the population and for the condition being checked; acceptable sensitivity and specificity; and have a well-defined cut-off point.

During the first contact, the PRISMA-7 should be used, developed in Canada for screening ²⁴ risk of functional loss in older adults¹². Comprising 7 items, a validated, transculturally-adapted version of the scale for use in Brazil showed the ideal cut-off for the population to be 4 points (4 or more positive responses). The scale requires no special materials, qualification or extensive training and can even be self-administered. Application time is 3 minutes and sociocultural and educational level do not influence comprehension of the questions.

The PRISMA-7 has been used systematically at the “front door” to the health system in Canada and by the British Geriatrics Society and Royal College of General Practitioners in the United Kingdom as a screening tool for functional loss and frailty³⁰.

Path to sustainability

Socioeconomic transformations and their consequent shifts in lifestyle in contemporary societies – with changes in eating habits, increased sedentarism, and stress, coupled with the rising life expectation of the population – contribute to a higher incidence of chronic illnesses which today represent a serious public health problem³¹.

The way forwards is to take the right steps, with focus centred on the most important element in the whole process: the patient³². Care should be organized in an integrated fashion and treatment coordinated throughout the care pathway in a network logic ⁸,³⁰. The model should be based on early identification of risks of frailty of the user. Once risk has been identified, the priority is to intervene before the onset of illness, thereby reducing the impact of chronic conditions on functioning. The idea is to monitor health, not disease, within a logic of continued follow-up, varying only in terms of level, intensity and intervention scenario³³.

It is important to attain better more financially economical care outcomes. This requires everyone involved to understand the need for change and allow themselves to innovate in terms of care delivery, means of remuneration and assessment of the quality of the sector.

These steps will result in benefits, quality and sustainability not only for this population group, but also for Brazilian health as a whole.¹⁷ The effects of this change of model will be felt immediately by users. This transformation of the health system toward sustainability will become evident in the medium-term.

Care model

In international frameworks, the generalist physician or family doctor fully handles 85-95% of their patients, without the need for intervention by specialists. In addition, this doctor can recruit health professionals with specific backgrounds (Nutrition, Physiotherapy, Speech Therapist etc.), but it is the generalist who recommends them and performs referral³⁴.

The British model, the National Health Service (NHS), is centred on the generalist doctor who has a high resolutive capacity, called the general practitioner (GP) in the United Kingdom. This is a special doctor who earns a bigger salary than specialists and is highly valued by British society. General practitioners are considered the “true doctors”, because they “know everything”. Specialists are generally perceived as being more limited since they only have expertise in a single specialty. For British citizens, good doctors are GPs¹, who have a close bond with the patient²⁵. Universal access to these professionals is guaranteed, regardless of income or social level, akin to the Brazilian SUS³⁵. When registering with a GP, British citizens receive free state medical care at health clinics manned by a team consisting of generalist physicians and nurses. Any treatment needed, if not extremely urgent or due to an accident, will be administered at the local clinic³⁶. By contrast, under the North-American model, patients are referred to numerous specialists. These are two wealthy countries with a long tradition in medicine. They operate, however, different systems which provide very different results³⁷.

A recent study involving developed countries conducted by the Organization for Economic Co-operation and Development (OECD), showed the difference in health costs in the US compared with other wealthy countries with good quality care³⁸ – where, naturally, spending on health care is larger than in developing countries²⁶,²⁹. Nevertheless, spending by North-Americans is far greater. In 2017, spending per capita reached US$ 10,224, or 28% higher than in Switzerland and over double that of the UK. These figures highlight that investing heavily in the treatment of diseases does not suffice.

In some countries, accreditation and assessment of quality indicators are obligatory requisites. In Brazil, priority is placed on volume. There is no policy for incentivizing quality. Patients do not always recognize this as a need, and both public and private health providers regard this as an extra cost. Although these needs are acknowledged by most health managers, little is done to improve the situation. Thus, for a well-structured care model ²², some elements cannot be left out⁴.

It is evident that the Brazilian system has an excess of consultations by specialists, because the current care model follows the North-American logic, promoting fragmentation of care²⁶. Quality care requires greater awareness from health managers and society.

The model proposed here is structured around low intensity levels of care, i.e., lower costs and consisting basically of care delivered by well-trained health professionals and involving epidemiological screening instruments, besides the use of monitoring technologies²⁹. It is paramount, especially in today´s world, that information pertaining to clients and their electronic medical records are available on the cloud, accessible from computers or cell phones anytime and anywhere, so that physicians and other health professionals may monitor the client when necessary³⁹.

A concerted effort should be made to ensure that patients remain within the sphere of low intensity levels of care, in a bid to maintain their quality of life and social participation. The target goal is to keep over 90% of older adults within this level of care³⁹.

Ideal age cut-off

In this section, the portfolio of clients should contain individuals aged 50 or older. Too young? Not exactly. However, the Statute of Older People, enacted by Law no. 10.741, in October 2003, is a set of laws to defend and protect individuals defined as older citizens.

Although not officially considered older adults, the epidemiology shows that it is from this age that chronic diseases begin to manifest. And the earlier the structure of a model of education in health and prevention is established, the greater the chances of success.

However, defining a cut-off from 55 or 60 years and older is also possible. In Brazil, being aged is defined as occurring from 60 years onwards.

The team

Teams are based on a duo of professionals: a geriatric doctor and a gerontological nurse. This pair is responsible for the health of a portfolio of around 800 clients. Working weeks are defined at 20 hours for doctors and 25 for nurses. The geriatrician performs clinical management; the nurse, specialized in Gerontology, acts as care manager, monitoring the health status of users and consolidating the role of contact person for support and of strengthening ties with the patient´s family.

A brief functional evaluation is carried out on the first contact. This serves as a reference baseline for monitoring and as a parameter for following the therapy plan between different points in the system. The care manager is tasked with overseeing the transition of care between services and revaluates the patient´s functional capacity annually, or as and when necessary, encouraging their participation in the process. The care manager´s function is key to the model proposed and their involvement mirrors that of navigator in the North-American system, a role created to help guide more frail patients.

The function of navigator can be found in some providers/operators in the United States and their role is central in the present proposed framework. According to the American Medical Association, this professional is responsible for managing the care of users throughout the different levels of complexity of the health system, checking whether prescriptions and orientations are being observed³².

Besides the geriatrician and nurse, the multidisciplinary team consists of a physiotherapist, psychologist, social worker, speech-language therapist, nutritionist, physical educator and workshop leaders (professionals engaged in integrative dynamic activities linked to the program). In the event that user care needs are identified at other levels of care, referrals are made to specialists but always via the generalist doctor.

It is important to point out that the model does not retain specialists, with some exceptions, such as when there is a large contingent of frail individuals at a clinic. In this case, six specialized areas related to the model are recommended, because these are part of the annual evaluations, or aiding the generalist doctor, given their specificity, demand and high prevalence. These specialties are in areas in which annual preventive and control exams are conducted, namely: Cardiology, Gynaecology, Uro-proctology, Dermatology, Speech-Language therapy, Ophthalmology and Otorhinolaryngology/ENT (this professional need not be a doctor but rather a speech-language therapist).

Consultation with the specialists listed is only possible upon request by the patient´s GP. Thus, if the client requires care of a given specialist, the other specialties will not be involved. The same reasoning applies to hospital admission. Doctors and nurses are in charge of contacting the physician of the hospital, to be briefed on the case, preferably seeking to ensure best care with shortest hospital stay.

Client entry

Patient entry in this care model occurs via an action referred to as reception, which takes place in two stages: the first stage is administrative and institutional in nature, when an in-depth presentation of the actions proposed is made, with an emphasis on health promotion and disease prevention. Users thus have a better grasp of the model and the overall dynamic of differential care which will be offered to improve their health and quality of life. Participation of older users in this dynamic should be encourages, because this is pivotal to attaining good outcomes²¹.

In the second stage of reception, the care commences proper. In order to organize access to the levels of the model, a risk identification screening questionnaire is applied: the PRISMA-7 ³³. After application of this rapid screener, the result will be stored on the information system. The patient then completes the other instruments comprising the functional evaluation. The functional evaluation entails a 2-step process, employing validated reliable instruments adopted by the leading geriatric research groups.

One of these is the Clinical-Functional Vulnerability Index-20 (IVCF-20), which measures 8 dimensions: age, self-rated health, daily living activities (3 instrumental and 1 basic ADL), cognitive status, mood/behaviour, mobility (reach, grasp and pinch grip; aerobic/muscle capacity; gait and urinary/faecal continence), communication (vision and hearing) and presence of multiple comorbidities, indicated by polypathology, polypharmacy and/or recent hospital admission. Each question is scored specifically according to the performance of the subject⁴¹ for a total of 40 points. In addition to the questions, several measurements, such as calf circumference, gait speed and weight/body mass index, are included to increase the predictive value of the instrument⁴².

Scoring is categorized into 3 classifications: 0-6 points, the respondent likely has low clinical-functional vulnerability and does not require further assessment or specialist follow-up; 7-14 points, indicates increased risk of vulnerability and the need for more in-depth assessment and attention to identify the appropriate treatment for chronic conditions; ≥15 points²⁴, deemed high risk of vulnerability or existing frailty requiring more comprehensive assessment, ideally by a team specialized in geriatric-gerontological care with psychosocial supportl⁶,¹⁰. The group headed by Professor Edgar Moraes⁷,⁴³, of the Federal University of Minas Gerais (UFMG), has made the instrument available on-line (https://sistema.medlogic.com.br/ngIVCF20/ge/ standalone/671/646>).

The other instrument is the Lachs Scale⁴⁴, applied after the IVCF-20. This probes other areas thereby conferring further robustness to the assessment results. This is an 11-item scale (questions, anthropometric measurements and performance tests) assessing areas commonly impaired in older adults: visual acuity, hearing, upper and lower limbs, urinary continence, nutrition, cognition and affect, ADLs, home environment and social support. The application of this instrument provides a rapid systematized means of identifying functional domains that should be subsequently assessed in more detail to establish a diagnosis and plan interventions.

In addition to risk identification and screening protocols, other epidemiological instruments are applied annually: the Katz scale – assesses basic activities of daily living ⁴⁵; Lawton´s scale – assesses instrumental activities⁴⁶; Mini evaluation of nutrition⁴³; Tinetti scale – test of balance and gait⁴⁷; the Jaeger Card – assesses visual acuity⁴⁸,⁴⁹; Mini-Mental State Exam (MMSE) by Folstein⁵⁰; and the Geriatric Depression Scale (GDS) by Yesavage⁵¹.

The doctor is the manager of follow-up and also of the interprofessional geriatric team, performing more in-depth assessment toward devising an intervention plan. This information will be collected and stored until the end of the care pathway. After this assessment, an individual therapeutic plan is defined that includes regular appointements²¹, referral to the multidisciplinary team, community centres, and if applicable, assessment by specialists.

A unique longitudinal and multi-professional electronic medical record is then set up and used to store information at all levels of care under the care model, from first contact to end-of-life palliative care. This record should contain information on the patient´s clinical history and physical exams, but also includes information on daily routine, family and social support etc. Information from other health professionals such as physiotherapists, nutritionists and psychologists etc. should also be held. Participation of the family, explanation of activities, and epidemiological screenings are other important features of this model (Figure 2).

Figure 2
Care Pathway, Rio de Janeiro, Rio Janeiro state, Brazil, 2023.

Information on all procedures is fundamental to allow monitoring of the client ⁵.

One of main factors for controlling costs of the program is follow up at each level of care. This ensures there are no gaps in patient care when the case is referred to the care network, tertiary care is required or hospital-level treatment⁵¹. The transition across care levels is overseen by the management team, which strives to maintain a smooth flow of information, liaising with assisting professionals and seeking to adhere to the principle of management predominantly by the geriatrician-nurse pair.

The control of hospitalization takes place via a flow to aid the client, ensuring that the health professionals assigned to the case are aware of the patient´s clinical and therapeutic history, as well as the understanding that the individual has frequent follow-up and is set to return to their health team when the clinical condition has been controlled⁵².

In the event of hospitalization, patient monitoring is performed daily on 2 fronts. For the first, the nurse keeps in touch with the family to provide support, clarification or to identify needs (pertaining to patient or family). The other front involves the prevention manager who provides liaison between the outpatient clinic and hospital, performing daily follow-up with the attending hospital physician. In hospitals which have internists, this contact is facilitated and direct. In other hospitals, support is provided by medical auditors or by the care team.

Thus, when the older adult needs to be admitted to hospital, this takes place more quickly, avoiding unnecessary procedures or admission to intensive care, ensuring post-discharge transfer³⁰ to low intensity level care settings, without the need to consult several specialists⁵³. This all culminates in higher quality care, with a significant cost saving and positive impact on the medical loss ratio⁵⁴.

Technology features

A high-quality information system and lightweight technology is essential in helping to win the confidence of clients. Without using technology, the project cannot go forwards and competence is needed to use it to the full.

For example: the client, upon reaching the front-door of the health centre, may undergo facial recognition which automatically brings up their medical record at the reception desk. When receiving the client, the receptionist addresses them by name, enquires after the family and checks the list of medicines they are using.

Another important feature is the availability of a cell phone app containing individualized information and reminders for appointments and prescribed actions. The app can, among other functions, request the client to take a photo of their breakfast and forward this to the nutritionist³⁸, who can then check whether the meal is balanced, contains adequate dietary fibre etc.

Although extremely simple, these actions confer great trust, making the client feel protected and valued from day one.

The information system, which commences with registration of the beneficiary, is one of the pillars of the program. The entire care journey will be monitored at each level, checking the effectiveness of actions and contributing to decision-making and follow-up. This entails a unique electronic record that is longitudinal and multi-professional, and accompanies the client from initial reception, providing an integral assessment of the individual.

The context of the pandemic and lockdown posed numerous challenges for medical practice. In the proposed system, contact with the client can be increased, since, besides face-to-face meetings, consultations via telemedicine are also incorporated⁵⁵. The aim is not to replace encounters in person, but to introduce flexibility and convenience for scheduling times and days for consultations, given that neither the doctor (or nurse) nor the patient need travel to attend the session.

The use of the latest technology provides closer contact of the health team with the client and family members. With a platform specifically designed for this care, the contact of gerontologists will be increased, enabling numerous individual or group-based actions involving a nutritionist, psychologist or physiotherapist, with counselling and broader contact with clients.

Besides the interdisciplinary team which delivers care directly, the model boasts a team of doctors and nurses working virtually. This constitutes a GerontoLine relationship channel, guaranteeing the users coverage 24/7. In passive mode, this receives calls from clients for guidance; in active mode, the team contacts patients on a regular basis keeping them on the care radar. Favouring this interaction, the professionals coordinating care (online) have access to the key information help in each patient´s medical history.

GerontoLine differs from call centres, commonplace in traditional health services and which typically operate with poorly-trained staff who have a reputation for overuse of clumsy gerund phrases”⁶ and offer no support if the client´s question or query falls outside the script. With GerontoLine, which is available 24 hours a day, 7 days a week, the call is answered by trained health professionals who have access to the patient´s records and, thus, have everything at their disposal to resolve problems.⁵⁶ Should an ambulance need calling in the middle of the night, this professional handles the whole referral process. In the event of a call during the early hours, this attendant will send a message out to the doctor, explaining the reason for contacting them. Hence, first thing in the morning, the doctor can take the first measures necessary. In other words, the patient and their family members feel protected, since they know that if needed, there is a qualified telephone service available to them.

In order for the GerontoLine to work smoothly, a comprehensive patient record is required⁵⁷ which documents not only clinical issues, but also behavioural, social and family aspects, where a global view of client needs are necessary for this model. Another benefit is the epidemiological assessment instruments which are applied at the first consultation, and repeated annually thereafter, or sooner if a special need arises.

Comprehensive Geriatric Assessment (CGA)

This is systematic assessment method. The CGA is based on the principle of an interdisciplinary planned approach aimed at treatment and long-term follow-up. CGA is a set of techniques and procedures, whose comprehensive assessment is structured around the classic non-standardized methods of health evaluation of a number of specialties. The most used dimensions in the CGA include functional status, mental health and social functioning.

Functional status is the base dimension for geriatric assessment. This essentially covers assessment of physical, psychological and social factors which impact the health of older more frail patients.

Mental health has two major subdimensions – cognition and mood – which also Interact with the assessment of functional state.

CGA is considered the gold standard for management of frailty in older adults.

Assessment of activities of daily living (bathing, toileting, transferring, continence and feeding), instrumental ADLs (using the telephone, shopping, preparing meals, handling medications and finances) and mobility (balance, gait speed and limb strength) can contribute to generate important information for decision-taking, mapping individual protection and risk factors.⁵⁸

The medical-health activities of health education can broaden its focus of attention to encompass positive dimensions of health beyond controlling specific diseases⁵⁹.

Screening of hearing/vision, and help in management of the use of multiple medications (polypharmacy) precede the detection of problems, contributing to care. Health habits (protective factors) include balanced diet, regular physical exercise, stimulating social interaction, occupational activity and well being actions in the field of nutrition (cuisine for diabetes and osteoporosis, for example) ⁴⁸.

Community centres

With the steady growth in the older population, some education programs focused on leisure have been developed. The first Brazilian experience of education for middle-aged and older adults was implemented by the Social Service of Commerce (SESC) in the form of community groups. These groups emerged in the 1960s running programs centred around leisure activities. These were welfarist in nature in as far as they did not offer the tools needed for people to regain the desired autonomy. From the 1980s, universities began to provide educational programs for the older population and for professionals wishing to study aging-related issues, predominantly offering education, health and leisure⁶⁰,⁶¹.

Similar centres had also been set up by health maintenance organizations following the release by the National Agency of Supplemental Health (ANS) of the Care Plan for Older Adults in Supplementary Health. The document sets out incentives to foster a change in the care logic, providing opportunities for health promotion for older people. A resolution was also published which encourages health plan beneficiaries to take part in active aging programs, in exchange for discounts on their monthly fee⁶¹.

Under the present model, setting up community centres is in line with the National Health Policy for Older Adults⁶². The primary goal is to recuperate, maintain or promote autonomy and independence of older individuals, as well as foster active healthy aging, with encouragement to participate and boost social interaction.

The centre offers a range of activities which contribute to healthy aging, development of autonomy and social interaction, strengthening of family ties, community involvement and prevention of situations of social risk for individuals aged ≥ 60 years⁶³. The programs, besides offering physical exercise, feature cognitive training, nutritional programs⁶⁴, telephone services, computing, home security, fall prevention, urinary/faecal continence, immunizations and financial management. Care with mobility of older people, fall prevention and balance in workshops for psychomotricity, strength training, advice on choice of footwear and podology service, are all important because they help maintain independence⁶⁵.

Aging requires adaptation. New learnings serve as a resource for maintaining functioning and flexibility of older people⁶⁶. Art, cultural and recreational activities are traditionally associated with community centres for older people and represent important sources of pleasure: general knowledge, languages, information technology, composing texts and reading, patchwork art, ballroom dancing, music, card games, dominoes, chess, meditation and sightseeing trips.

Community centres can provide legal aid services, a caregiver agency and help for the housebound (support for ADLs, remote assistance and meal deliveries etc.). To this end, investment in courses for training caregivers and in communication in the care network are essential. Also, regularly frequenting workshops allows the older person to experience a routine, which also benefits the caregiver who is freed up to engage in other activities. An annual or six-month “contract” for older adults to attend workshops, as they see fit and subject to the availability of coordinators, facilitates management.

As a tool for planning aging, there is the Time Trade-Off questionnaire, which allows a negotiation between the health professional and older individual, considering risk and pleasure. Many retirees rejoin the job market on a regular or sporadic basis, whether for pleasure or due to necessity, topping up income and stimulating social contact. In the USA, many dedicate time to voluntary projects.

The centres can also provide a forum for discussion of issues affecting the older individual. Aging and end-of-life warrant focus. A practical, fun guide can be devised addressing frequently asked questions or FAQs in relation to aging (e.g., “what is happening to me?).

Philosophy and religion can contribute to reflection on aging and death. According to Plato, in Ancient Greece, to philosophize was learning how to die. An idealist, he believed in life after death, regarded this as a passage, a liberation of the soul. For materialists, however, such as Epicurus, life was finite, making it even more valuable. One cannot live the same when believing in such different conceptions of death⁶⁷.

The experience of ageing is both heterogeneous and multidimensional, thus calling for singularity also in care plans⁶⁸. Quality or functioning of social support is more important for adaptation of older individuals than the number of people in the network or the frequency of contact⁶⁹. Indeed, the association between social support and self-care supports this notion⁵⁴.

Hence, Community Centres have found their place based on the premise that whoever works with the perspective of respecting the needs of older people respects their own future.

Parallels

In the line of care during the human life cycle, childhood and old age share similarities. Young children, people with chronic diseases and older individuals – in fact, all those with limited autonomy and independence – require special care. Public entities, such as crèches and community centres, can add to the options of support and monitoring, intergenerational care approaches and broaden patterns of social integration. Expansion of support networks and of resources to deal with limitations enriches the life experience.

Many families are tasked with looking after children and old people. With the advent of pensions in the 20^th century, these families began sharing this responsibility with companies and the state. The building of care networks represents a considerable relief for families, increasing their chances of meeting the challenge of their responsibilities. However, power exists in all human relationships. How can others be empowered while avoiding a relationship of guardianship? How can a situation be avoided whereby caring becomes an act of domination? It is paramount to manage the realm of power present in all relationships carefully and to reject strategies of domination. Relationships based on dialogue, a person-centred approach, negotiation, and co-responsibility make all the difference. It is important to discuss the question of the quality of the caregiver/care recipient relationship, as well as the possibilities of transforming the relationships of power.

At community centres, studies recommend the use of measures of quality of life based on self-rating by the users: “how would you rate today?”. This approach boosts self-esteem, instils a sense of governability and contributes to the devising of a personalized care plan every day⁶¹.

Such centres can provide the incentive for older people to go out regularly and offer the opportunity of social contact. Community centres can also stimulate the formation of a communication network centred around care, forging a relationship of trust between the older adult, their family members and professionals from the institution. The existence of shared spaces to exchange information and experiences, as well as everyday informal interactions, help bring interlocutors together. In the care network, the role of different actors should be discussed and negotiated on an ongoing basis, given their needs and possibilities also undergo change. To this end, forums of communication, such as groups for reflection and conversation circles, reaffirm the importance of collective construction (older adults, caregivers and professionals) of the daily routine. Workshop leaders should be trained and integrated based on the premises of accompanying human aging.

In the Berlin Aging Study⁷⁰, an extensive interdisciplinary study involving 516 randomly selected older adults aged 70-100 years conducted in the city of Berlin, Germany between 1990 and 1993, different variables were analysed, including medical (functional capacity, risk profile, reference biological values), sociology and social policy (life history and generational dynamic, family structure and dynamic, economic situation and social security, social resources and social participation), and also psychology parameters.

In community centres, cohort studies can contribute to the knowledge and organization of care of the group of older users. In the USA, there are cohorts of older adults who frequent community centres during the course of aging. The epidemiologic information obtained enables health to be monitored and problems detected early or avoided, with the goal of extending the healthy life of older people¹⁹,³³. At these centres, multiple dimensions of care can be observed through leisure-time and instrumental activities.

Care venues

The older age group is increasing and growing older, baby-boomers are reaching the “third age”. Life expectancy continues to rise. This is accompanied by a growth in the care technology pertaining to this stage of life, which can now span 40 years. Community centres need to both increase in number and recognition. Solutions are mixed: individual and singular, but also collective.

For a long period, the crèche institution evoked a certain distrust, being associated with an orphanage, a place where children were abandoned⁶¹. Institutions which care for older people for some hours of the day, such as community centres may also conjure connotations of old people´s homes, nowadays referred to as long-term care facilities, and sometimes identified as places where elderly are left and abandoned.

Today, there is prevailing consensus on the importance of socialization of young children. Similarly, the important role of community centres in preventing social isolation of older people is clear. There is a tendency for older individuals to have fewer social contacts and relationships with advancing age. Frequenting the institution also provides routine and rhythm, conferring structure to their everyday lives. Sociability networks of older people can occur in different settings, such as squares, beaches, clubs and religious activities, or in collective entities such as community centers⁶¹.

Institutions that host older residents, albeit short or long-term, may be part of an external network, forming venues of interaction. Receiving external family members and older adults for activities together with the older residents, provides the interaction and workings of a support network⁷¹. This can be exemplified by a German experience which promoted, within the same building, a community centre running daily activities for older people, health services (outpatient clinics and day-care hospital), care for housebound individuals and long-term care facility. Preventing disability and recouping autonomy through rehabilitation programs – all or a combination of these forms of care under the same roof – are actions which widen the range of possibilities. The pre-old, young-old and oldest-old all experience similar situations which often precede different stages of limitations in functioning. Resources and solutions also multiply, in as much as autonomy and independence also change during this phase⁷².

Care centres may provide a range of care for children, individuals with temporary or permanent disability and older individuals, with or without autonomy and independence. Crèches, when opening their doors to older visitors for activities together with the children, provide interaction and allow affective ties to form between generations. The conveying of values, life stories told in photos, recipes or songs and sharing meals together, for example, value the older generation, conferring a place of importance and acting as a motivator. Fostering ties and the ability to pay attention to one another, is a natural consequence of these shared activities.

Birthplace of the model

An example of the model presented was developed within the Open University for the Third Age of the University of the State of Rio de Janeiro (UnATI/UERJ), an institution set up 29 years ago that has gained national recognition as one of the most important health programs for middle-aged and older adults⁷³. This initiative has also garnered international awards and been endorsed by the World Health Organization. The UnATI/UERJ is a centre for studies, education, debates, research and assistance addressing issues inherent to aging, which has contributed to a change in mindset of Brazilian society regarding its attitudes to older generations.

An innovative quality care system must be built, because the prevailing outdated care model, unless replaced, will only exacerbate the current poor service and healthcare crisis, particularly for older adults, the age group placing the greatest demand and cost on the system.

CONCLUSION

In recent years, I have been dedicated to researching the integral care of older people and refinement of care models. In the capacity of Director of the UnATI/UERJ and my role as Editor of the Revista Brasileira de Geriatria e Gerontologia (RBGG-Brazilian Journal of Geriatrics and Gerontology), I have witnessed the desire (and need) to consolidate the structuring of the care model for older adults.

I often receive comments of praise, yet, these are invariably tempered by the remark: “what you write is so obvious that maybe this is why it´s so hard to put these ideas into practice”. I tend to agree.

And it is precisely because I realize these reforms are increasingly imperative with each year that goes by, that I continue striving to bring this matter to the attention of academics and opinion leaders in the health sector, because a further dose of medicine is sorely required which, it is hoped, will be able to remedy the present ailing care model.

Population aging is accompanied by new demands, and challenges the traditional care model. Advancements in technology, science and medicine offer those who embrace the modern tools for maintaining health the chance to enjoy life for longer. The social and economic transformations of the last few decades, their consequent shifts in behaviour of contemporary society – changes in eating habits, increased levels of sedentarism and stress – and growing life expectancy of the population, have contributed to higher rates of chronic diseases, posing a major public health problem. The health needs of the older population cannot be satisfactorily met until it is recognized that this stratum of society requires specific care. This makes overhauling the current health model imperative.

Scrutiny of the national health budget reveals that the vast bulk of funds is dedicated to hospitals and equipment for performing complementary exams. Society and health professionals alike, as a general rule, adhere to a logic grounded in hospital institutions, with a mindset of only treating diseases as opposed to preventing them.

The ideal care model for the older population should be centred on identifying potential risks. Monitoring health instead of disease will direct investment toward early prevention, resulting in a better chance of rehabilitation and reduced impact on functioning.

As a response to the older population, more actions focused on health promotion and education, the prevention and delaying of disease and frailty, besides maintenance of independence and autonomy, should be implemented. Lastly, increasing longevity alone does not suffice. As outlined above, it is vital that these additional years can be lived with quality, dignity and wellbeing.

In sum, with concerted efforts, excellence in care for the older population can be achieved and made sustainable, transforming care not just for this segment, but for the health system as a whole.

A novel approach to health care that promotes quality of life for users – albeit under the SUS or via the private sector – will entail the use of qualified well-prepared professionals, integrated care, and judicious deployment of information technology. This is the shape that contemporary resolutive models advocated by leading national and international health organs should take. And this is what we wish to see in the not-so-distant future.

• The author declare that there is no conflict in the conception of this work.

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Edited by

Edited by: Luiz Antonio Costa Tarcitano

Publication Dates

• Publication in this collection
  22 May 2023
• Date of issue
  2022

History

• Received
  16 Mar 2023
• Accepted
  13 Apr 2023