Journal of Medicine and the Person

, Volume 9, Issue 1, pp 6–12

The frail person and his caregiver: cure, care or simultaneous care? A conceptual article

  • Michele Vitacca
  • Clementina Isimbaldi
  • Angelo Mainini
  • Mario Melazzini
Original Article


The greatest challenge we face over the next 20 years is the management of chronic diseases in an elderly population. Older adults in poor health are at risk of negative outcomes and are the major consumers of health resources in hospital or in community settings. As a consequence, the medical, social and organizational solutions for frail people with chronic disease must resolve a complex situation. The caregiver is a key to the care of the frail patient with chronic diseases, acting both as point of reference and support giver. The caregiver inside the family is becoming increasingly both the supplier of care as well as the subject of that care with its matrix of important physical, psychological, relational and working consequences. The aim of the present article is to focus on the cultural and organizational pillars of guaranteeing care and assistance as well as to consider as a whole both the frail patient and their caregiver. The chronic patient almost always has some disability because of his or her history of clinical complexity, with several comorbidities and social fragility. Such a patient requires a multidisciplinary approach and at the same time needs an individualized of care in order to optimize his or her physical and clinic condition, quality of life and social involvement. Therefore, the patient’s need is not only clinical but also social and multifaceted. Continuity of care is inevitably the solution for the frail patient. This would be based on an integrated net of services including hospitals for acute admissions, intermediary structures, centers of rehabilitation and long-term admission, homecare and primary care services all working with real dialogue, communication and integration. A general consensus on which follow-up program can be most effective for chronic patients is still lacking. The most important function for good continuity of care is what is technically called “case management”, which is the ability to activate all the necessary resources to deal with the various different needs of the individual patient. Continuity is founded on two poles: on the one hand patient care from local general practitioners and home-care services and on the other hand hospital admission or out-patient services for specific diseases. To ‘network’ means to think of the projects in terms of “Hub and Spokes” with centralized expertise that spreads and branches to the regions. To ‘guarantee continuity’ means to integrate social services in local areas and other relevant competent authorities using methodologies of empowerment and development of expertise. In preparing the guidelines, it is essential to think about the whole process of patient care as a virtuous circle of listening, planning, programming and verification in the field. Guarantee of continuity of care should be a fundamental contractual principle both for the one who pays and for the one who disburses the service. However, it is not enough to only treat the specific illness; there is a need to take into account not only the symptoms of this illness but also the medical complexity of other factors involving the whole person. An organizational answer is not enough to bridge this gap; formative education both in university and school is needed. Indeed, a culture is needed that changes the physicians’ focus on patients as individual person within the population that focuses on his holistic care. The future of chronic and frailty care follow-up systems depends on: (1) human factors, (2) economics and (3) technology. The real “technology” is the human resource available in hospitals, homes and health and social care organizations. New care models need to respond to criteria of equity, simplicity, efficiency, efficacy, safety and patient-centeredness.


Continuity of care Chronic care Aged 


  1. 1.
    American College of Physicians (2008) E-health and its impact on medical practice.American College of Physicians; Philadelphia. Position Paper.
  2. 2.
    Young HM (2008) Challenges and solutions for care of frail older adults. J Issues Nurs 8(2):5Google Scholar
  3. 3.
    World Health Organization Global Observatory for eHealth (2005) Global E-health survey Geneva.
  4. 4.
    Ministers of EU Member States Ministerial Declaration (2003) eHealth, Brussels.
  5. 5.
    Istituto Nazionale di Statistica (2005) Statistica in breve. L’integrazione sociale delle persone con disabilità anno 2004. ISTAT, pp 1–13.
  6. 6.
    Langa KM, Fendrick AM, Flaherty KR, Martinez FJ, Kabeto MU, Saint S (2002) Informal caregiving for chronic lung disease among older Americans. Chest 122:2197–2203PubMedCrossRefGoogle Scholar
  7. 7.
    Levesque L (2010) A partnership approach to service needs assessment with family caregivers of an aging relative living at home: a qualitative analysis of the experiences of caregivers and practitioners. Int J Stud 47(7):876–887Google Scholar
  8. 8.
    De Girolamo G, Rucci P, Scocco P, Becchi A, Coppa F, D’Addario A, Darú E, De Leo D, Galassi L, Mangelli L, Marson C, Neri G, Soldani L (2000) Quality of life assessment: validation of the Italian version of the WHOQOL-Brief. Epidemiol Psichiatr Soc 9(1):45–55PubMedGoogle Scholar
  9. 9.
    Celli BR, MacNee W; ATS/ERS Task Force (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 23(6):932–946Google Scholar
  10. 10.
    Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R (2005) Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 171(9):972–977PubMedCrossRefGoogle Scholar
  11. 11.
    de Voogd JN, Wempe JB, Koëter GH, Postema K, van Sonderen E, Ranchor AV, Coyne JC, Sanderman R (2009) Depressive symptoms as predictors of mortality in patients with COPD. Chest 135(3):619–625PubMedCrossRefGoogle Scholar
  12. 12.
    Van Pelt DC, Milbrandt EB, Quin L, Weissfeld LA, Rotondi AJ, Schulz R, Chelluri L, Angus DC, Pinsky MR (2007) Informal caregiver burden among survivors of prolonged mechanical ventilation. Am J Respir Crit Care Med 175:167–173PubMedCrossRefGoogle Scholar
  13. 13.
    Douglas SL, Daly BJ (2005) Caregivers of long-term ventilator patients. Chest 123:1073–1081CrossRefGoogle Scholar
  14. 14.
    Moroni L, Sguazzin C, Filipponi L, Bruletti G, Callegari S, Galante E, Giorgi I, Majani G, Bertolotti G (2008) Caregiver Need Assessment: uno strumento di analisi dei bisogni del caregiver Giornale Italiano di Medicina del Lavoro ed Ergonomia Supplemento B. Psicologia 230(3):B84–B90Google Scholar
  15. 15.
    ATS Documents (2005) Statement on home care for patients with respiratory disorders. Am J Respir Crit Care Med 171:1443–1464Google Scholar
  16. 16.
    Tougaard L, Krone T, Sorknaes A, Ellegaard H (1992) Economic benefits of teaching patients with chronic obstructive pulmonary disease about their illness. Lancet 339:1517–1520PubMedCrossRefGoogle Scholar
  17. 17.
    Adams SG, Smith PK, Allan PF, Anzueto A, Pugh JA, Cornell JE (2007) Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management. Arch Intern Med 167:551–561PubMedCrossRefGoogle Scholar
  18. 18.
    Haggerty Mc, Stockdale-Woolley R, Nair S (1991) Respi-care: an innovative home care program for the patient with chronic obstructive pulmonary disease. Chest 100:607–612PubMedCrossRefGoogle Scholar
  19. 19.
    Littlejohns P, Baveystock CM, Parnell H, Jones PW (1991) Randomized controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation. Thorax 46:559–564PubMedCrossRefGoogle Scholar
  20. 20.
    Cockcroft A, Bagnall P, Heslop A, Andersson N, Heaton R, Batstone J, Allen J, Spencer P, Guz A (1987) Controlled trial of respiratory health worker visiting patients with chronic respiratory disability. BMJ 294:225–228PubMedCrossRefGoogle Scholar
  21. 21.
    Richards SH, Coast J, Gunnell DJ, Peters TJ, Pounsford J, Darlow M-A (1998) Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with hospital care. BMJ 316:1796–1801PubMedGoogle Scholar
  22. 22.
    Sheppard S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P (1998) Randomized controlled trial comparing hospital at home care with inpatient hospital care. BMJ 316:1786–1791Google Scholar
  23. 23.
    Donner CF, Pesce L, Zaccaria S, Erbetta M, Mazzetti D (1993) Organisation of home respiratory care in Italy. Monaldi Arch Chest Dis 48(5):468–472PubMedGoogle Scholar
  24. 24.
    Sturani C (2006) Respiratory home care: reality and perspectives. Rassegna di Patologia dell’Apparato Respiratorio 21:272–279Google Scholar
  25. 25.
    Hughes SL, Weaver FM, Giobbie-Hurder A, Manheim L, Henderson W, Kubal JD, Ulasevich A, Cummings J, Department of Veterans Affairs Cooperative Study Group on Home-Based Primary Care (2000) Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA 284:2877–2885PubMedCrossRefGoogle Scholar
  26. 26.
    Huges SL, Ulasevich A, Weaver FM, Henderson W, Manheim L, Kubal JD, Bonarigo F (1997) Impact of home care on hospital days: a meta analysis. Health Serv Res 324:415–432Google Scholar
  27. 27.
    Smith SM (2010) Humanbecoming: not just a theory—it is a way of being. Nurs Sci Q 23(3):216–219PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Michele Vitacca
    • 1
  • Clementina Isimbaldi
    • 2
  • Angelo Mainini
    • 3
  • Mario Melazzini
    • 4
  1. 1.UO Pneumologia RiabilitativaFondazione Salvatore Maugeri, IRCCSLumezzaneItaly
  2. 2.UO di Pediatria, Azienda Ospedaliera Ospedale di LeccoLeccoItaly
  3. 3.Direzione Sanitaria, Fondazione Maddalena Grassi MilanoMilanItaly
  4. 4.Presidente Nazionale AISLA OnlusMilanItaly

Personalised recommendations