Integrated continuous care: collaborating with the elderly functionality

This study aimed to evaluate the influence of Integrated Continuous Care on the functional independence of the elderly. This cohort study included participants aged 60 years or older who had experienced a disabling event or disease, and were admitted to rehabilitation in a Brazilian Integrated Continuous Care Unit. The functional gain was evaluated by the Barthel index. Fifty-nine elderly individuals admitted due to a disabling event or disease at the ICCU were assisted from March 2014 to February 2015. Since twenty-two of these were excluded, only 37 participants were evaluated. The mean age of the elderly that were included was 70.41 years (± 1.40) and most of them presented an ischemic stroke diagnosis (64.9%). The total functional gain was 24.05 (± 3.84) points, with an average stay of 32.32 (± 2.18) days. When compared with the degree of dependence on the admission and at discharge, total or severe dependence was identified in 62.2% on admission and mild dependence or total independence was identified in 54.1% at discharge, with a significant decrease in the percentage of the elderly with total dependence between admission and discharge (McNemar test, p = 0.001). At hospital discharge, 70.3% of the elderly had better individual performance in their Activities of Daily Living than at hospital admission and none of them got worse. The multi-professional team-based approach in the Integrated Continuous Care assistance model favors the elderly with gain in functionality and independence. The social network involvement of the elderly lead to their empowerment and co-responsibility along with their family/caregiver in pursuit of the therapeutic goals established together.