Aging Clinical and Experimental Research

, Volume 21, Issue 6, pp 414–423

A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly

Authors

    • Laboratoire «Santé Vieillissement», AP-HP, Hôpital Sainte PerineUniversité de Versailles St-Quentin
    • SolidageMcGill University — Université de Montréal Research Group on Frailty and Aging
  • Matthieu De Stampa
    • Laboratoire «Santé Vieillissement», AP-HP, Hôpital Sainte PerineUniversité de Versailles St-Quentin
    • SolidageMcGill University — Université de Montréal Research Group on Frailty and Aging
  • Howard Bergman
    • SolidageMcGill University — Université de Montréal Research Group on Frailty and Aging
    • Division of Geriatric MedicineMcGill University, Jewish General Hospital
  • Joel Ankri
    • Laboratoire «Santé Vieillissement», AP-HP, Hôpital Sainte PerineUniversité de Versailles St-Quentin
  • Bernard Cassou
    • Laboratoire «Santé Vieillissement», AP-HP, Hôpital Sainte PerineUniversité de Versailles St-Quentin
  • Claire Mauriat
    • Laboratoire «Santé Vieillissement», AP-HP, Hôpital Sainte PerineUniversité de Versailles St-Quentin
  • François Blanchard
    • Laboratoire «Santé Publique, Vieillissement et troubles cognitifs et du comportement», Hôpital SébastopolUniversité de Reims Champagne Ardennes
  • Emmanuel Bagaragaza
    • Laboratoire «Santé Vieillissement», AP-HP, Hôpital Sainte PerineUniversité de Versailles St-Quentin
  • Liette Lapointe
    • SolidageMcGill University — Université de Montréal Research Group on Frailty and Aging
    • Desautels Faculty of ManagementMcGill University
Special Article

DOI: 10.1007/BF03327446

Cite this article as:
Vedel, I., De Stampa, M., Bergman, H. et al. Aging Clin Exp Res (2009) 21: 414. doi:10.1007/BF03327446

Abstract

Despite strong evidence for the efficacy of integrated systems, securing the participation of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel approaches are needed to resolve these problems. We developed a model — COPA — that is based on scientific evidence and an original design process in which health professionals, including PCPs, and managers participated actively. COPA targets very frail community-dwelling elders recruited through their PCP. It was designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits and hospitalizations, and prevent inappropriate long-term nursing home placements. The model’s originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment and care plan development; 2) having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the PCP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community to see patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions. Since COPA is currently the subject of both a quasi-experimental study and a qualitative study, we are also providing preliminary findings. These findings suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results indicate that the level of service utilization in COPA was less than what is reported at the national level, without any compromises in quality of care.

Keywords

care managementelderlyintegrated careorganizational

Copyright information

© Springer Internal Publishing Switzerland 2009