Pr Dominique SOMME Geriatrics Department, Rennes University Hospital, France

1. In search of the best way to balance continuity of care and coordination between single oriented disease programs and community care based programs in France Pr Dominique SOMME Geriatrics Department, Rennes University Hospital, France Medical Faculty, Rennes 1 University, France dominique.somme@chu-rennes.fr

2. Is case-management helpful for Dementia? • Dementia as a « total disease » : reveals the care systems’ gaps • Case management was designed to cope with continuity and care coordination problems • Case management presents a huge diversity in its implementation according to programs and countries

3. 2009 Systematic review • Based on case-management/disease-management and care-management study • Only randomized controlled study • With Alzheimer’s disease patients (or associated disorder : dementia) • In community • The only difference between groups : presence or absence of a case management program

4. Results : 924 hits in databases  6 RCT

5. 2009 Systematic review • Has case management for persons with dementia been proven to be effective in randomized controlled trials ? • Sligthly • Which outcomes have shown case management to be effective in RCTs for persons with dementia? • Clinical ones • Which aspects of service programs might explain variations in their efficacy? • Case management intensity+++; non disease only oriented target • Might integration level of the system organization explain variations in program efficacy? • Yes • Somme D et al. Alzheimer and Dementia 2012;8:426

6. 2012 Systematic review • Is case-management useful for caregivers? (of frail elderly and persons with dementia) • 14 studies • 6 positive for the caregivers • 8 neutral for the caregivers (none positive effect reported) • None with a negative effect • Factors related to efficacy : • High intensity of case management • Dementia related programs • Corvol A et al. Proposed for publication

7. How did we implement case management in France? • During 2005-2008 period : PRISMA France experiment • Implementation study • Based on the PRISMA model successfully tested in Québec relying on 6 axis: • Coordination between institutions • Single entry point • Multidimensional standardized assessment tools • Individualized services plan • Shared clinical file • Intensive case-management • Research question: • Is it possible to move toward integrated care in France? • What are the factors influencing the implementation process? • Does it make a real difference of professional practices? • Does it make sense for the older people? • Three experimental sites (rural, urban, mega-urban) • Case management directed for people in loss of autonomy without any references of Alzheimer’s disease and dementia • Etheridge et al IJIC 2009; 9: Dec 16. Somme et al. In Hébert et al 2008, Trouvé H et al. IJIC 2010;10:30 june

8. How did we implement case management in France? • Results of the « professional practices » study: • Weakness of the implementation because of multiple simultaneous changes in the innovation process • Integrated care level as a regulating factor for the efficacy and the efficiency (case load of the case managers) • New professional practices (notably regarding the use of standardized assessment and planning tool)  development of a new professional identity  necessity for a specific professional training • New ethical challenges • Nugue et al. Care Mangag J 2012; 13:184; Corvol et al. Nurs Ethics 2013; 20:83

9. How did we implement case management in France? • During 2008-2012 period : the French Alzheimer plan • The 3rd French Alzheimer plan : a presidential mandate priority • 1 600 000 000 € new expenses (tax collected on all medical consultations) • 44 measures, 10 core measures • Measure 4: Creating « Homes for the Integration and Autonomy of people suffering from Alzheimer’s or associated disorders » (“MAIA”) • Not a new structure • But a innovative organizational mechanism • Which is adapted and implemented locally by taking into account the local priorities and reality and based on the 6 PRISMA model axis • Purpose: creating a collective seal of quality (exclusively delivered to a partnership, never to one structure) • Somme et al IJIC 2011; 11 ; Dec 14

10. How did we implement case management in France? • The challenge of introducing « intensive and generalist » case management inside an « Alzheimer plan » • Politicians, Policy-makers and Alzheimer association waiting for a « specialized coordinator » • Individual, professionals, managers, policy experimental project management team and researcher implementing a « generalist case manager » • Able to cope with multimorbidity • Able to intervene even when no diagnosis was made on « cognitive trouble » (psychiatric patient…) • Able to intervene with the loss of autonomy and its consequences whatever the cause of this loss • Not redundant if a new « Parkinson » or « other disease specific » new policy would be launched

11. How did we implement case management in France? • 17 experimental sites • Chosen by independent panel • > 100 candidates • Various territory unit (6km² to more than 7000km²) • Various situation (rural, urban, mega-urban) • Various health and services offer • Various organization responsible for the program (with or without political representation) • Various skills and professional background for persons accountable for the implementation (“the pilot”) • One axis : case management • Launching of the experimentations : • 2009, february : first meeting • 2009, june : pilots training • 2009, october : first case managers

12. How did we implement case management in France? • A new university specific training courses • All the case managers must followed the same training courses • Specificities of the training courses • An interdisciplinary approach taught by an interdisciplinary team • Emphasized on the assessment process of the needs, the use of assessment and planning tool • Good professional distance • Ethical challenges

13. Case management and integrated care delivery • In France the very high level of fragmentation of care is a major obstacle for case management if no reorganization is made in the same time • The case manager faced the limits of its legitimacy. • He cannot influence others’ actions by the multidimensional assessment if this assessment is not recognized as pertinent by his partners. • He cannot use the results of his assessment to give access to some services because all services stay with their own access process with professionals in charge to do the process. • He cannot go everywhere the client is, etc…

14. Case management and integrated care delivery • The case managers were introduced in the system very early in the implementation process (less than 6 months after the first work). • In the qualitative analysis of the implementation process, it was mostly a positive effect (reinforcement of the implementation) • Notably because the others dimensions of the ICD were more « real » with case managers. • Necessity to have « generalist » case managers to produce this kind of effect

15. Conclusion • Case management need to be intensive and in an integrated care context to be useful for Dementia patient • Case management as one component of an integrated services delivery process is useful to assure continuity of care and coordination • It is not only a clinical process that’s why it could be valued as a public policy initiative and not as a service provider initiative • As a component of an ISD process, case management need to be “generalist” and not “specialized” for a single disease • It is quite easier to interest politicians with single disease program (more visible) than with systemic change • We have to balance a single oriented “expertise” with a “generalist” field of intervention

16. Conclusion 2 • The French Alzheimer plan is a semi-success • Generalist case management was introduce in our system • A national public policy publicly funded aimed (to integrated) at integrating health and social care was launched in parallel and closely linked with case management • All case managers in France followed the same university program • This policy was continuously scientifically assessed with publication and ongoing work on new ethical challenges • The French Alzheimer plan is a semi-failure • No political speech on case management or integrated care • New concurrent public policy launched in 2012 for « frail » elderly and not related to case management or ISD process • The next step : the 2012 « autonomy » law

17. dominique.somme@chu-rennes.fr MERCI - tHANK YOU

18. Intensive case management • Case management: • case-finding • assessment • care planning • care co-ordination (usually undertaken by a case manager in the context of a multidisciplinary team). • This can include, but is not limited to: medication management; self-care support; advocacy and negotiation; psychosocial support; monitoring • regular re-assessment of the needs • High risk population (to be defined, in France : “complex” situation without any unique criteria…) • High intensity (direct contact with people, at home, more than 4 contacts/year, mean length of a multidimensional assessment of a situation > 2 hours, meetings schedule and animation with partners • Small case load (<60 in theory, < 40 in France and probably less) • Quality improvement approach • Two levels intervention : at the person level (« clinical ») and at a systemic level (« organizational ») in linked with the integrated care initiative • Challis, D et al. (2001) Age and Ageing, 30(5), 409-413.

19. Other imputs from scientific litterature • Cost of care for patients with a chronic disease (diabetes) is less than 50% related to care included in (the best-)evidence-based guideline for this disease. Most of the extra-cost are related to multimorbidity Christel E van Dijk et al IJIC 2011;11;14 déc • « Generalist care managers » could attend the same efficacy (led by) than specialist ones if they (re) are supported by adequate computerized tools (protocol and guideline) Dorr DA et al Health Services Research 2005;40:1400

20. Fragmentation of health and social services in France • Fragmentations : • Between the Health and Social services systems • Between Institutional (hospital and LTC) and Community based care and services • Between private, non-profit and public services • Between the various payment systems (public, insurances, fee-for services) • At all levels: clinical, tactical (services), regional strategic and national strategic (even at the State level) • Trouvé H et al. IJIC 2010;10:30 june

21. Results : 924 hits in databases  6 RCT

22. Qualitative research with first case managers • What do the training courses add? • Concept clarification : « You know…it is a revolution in our clinical practices » • Informal exchange between case managers during social times during the training curse • « I realized that my colleagues were in the same unclear state than me! But when we were talking of what is unclear between us, it was like that it was less unclear…In any case…That made more sense with what everyone bring in the talk finally. That was a building on our questioning… » • Importance of a alternating format of the training courses (with common university module alternating with professional exercise) • Need to continue the formation after the diploma by interacting between new professionals •  creation of an association and an Internet forum, participation in the years following the graduation, rich content of the returns, adaptation of the training courses