"Center of Geriatric Care" project- the development of the interdisciplinary home-based care model for elderly patients in Gdansk, Poland. Pilot study

Introduction: Integrated care for elderly patients is not a standard in Central European Countries (CEC). Lack of coordination between healthcare service providers and social support, and diverse financing has led to low effectiveness of the whole care system for elderly. Short description of practice changes implemented: "Center of Geriatric Care" project assumes development of integrated model of care for elderly patients, managed by interdisciplinary geriatric team. The essential aims are: to develop an effective, coordinated and integrated management, based on the patient-centred triangle consisting of healthcare providers - social workers – family. to educate patients and caregivers extensively with the intension of lowering deterioration and exacerbations of the underlying chronic disease. Aim and theory of change: The aim of the study is to improve the management of elderly patients, to decrease the incidence of exacerbations (especially those requiring hospitalisation), to hamper the deterioration of general health condition, and finally to reduce the cost of care. Target population and stakeholders: In the pilot study, the model of care would be delivered to 90 multimorbid elderly, recruited from three different healthcare pathways (primary care, n=30; patients with chronic heart failure, n=30; patients with chronic obstructive pulmonary disease, n=30). In our model, existing healthcare services will be broadened by: 1- Periodic evaluation by geriatricians with use of comprehensive geriatric assessment tools. 2- Regular home visits of specially trained carers, which include monitoring of general condition, encouraging appropriate physical activity and supporting adherence to medical recommendations, alerting about significant symptoms. 3- Comprehensive rehabilitation based on regular physiotherapy. 4- Using selected, simple e-health interventions. Timeline: 24 months. Highlights (innovation, Impact and outcomes): The primary outcome of the project is to design and testing of a model of home-based integrated care, which is innovative in Poland and CEC. The expected results include improvement in functional and cognitive status and quality of life of patients, followed by decrease in general demand for medical services, especially in-hospital, and selected health economics indicators. The secondary outcome is to increase the knowledge and competencies of social workers, nurses, physiotherapists and family memb