Summary
The service promotes comprehensive elderly care, aimed at maintaining autonomy of healthy older people, detecting and reversing frailty and high risk of falls and caring for people who already have different levels of functional impairment/degree of dependency. General practitioners, nurse practitioners and social workers working in the 262 primary care centres at the Madrid RS are the main stakeholders providing the service, which was co-created with an expert committee that represented them. Target population: people 70+; with severe/complete dependency living in Madrid. In 2021, number of users that could benefit from the good practice were 946,171 inhabitants; from those, 236,961inhabitants (21%) were covered by this service. The service stratifies the target population according to the degree of dependency based on the Barthel Index, and indicates different action plans with the most effective interventions proposed by clinical guidelines and ministerial plans. Frailty screening and risk of falls assessment are as well performed within this service using validated and standardized tools. Its implementation has required the development of personal care records plans in the electronic medical record of the Madrid Community (named AP Madrid), the training of health and social care professionals and the design of an evaluation model (annually performed). While target population has remained stable, the screened people increased in the second year of implementation. However, the screened people decreased during the last two years, because regular healthcare practices had to be reorganized due to COVID pandemic.
Planning and Implementation
-
What was the challenge you were trying to address?
The service has the aim of maintaining autonomy of healthy older people, detecting and reversing frailty and high risk of falls and caring for people who already have different levels of functional impairment/degree of dependency.
-
Who were you trying to impact?
Older people in general, Older people with chronic health conditions or disability, Older people with vulnerabilities
-
What sectors were you targeting?
Education, Health, Housing, Long-term care, Social protection
-
Who else was involved?
Government, Civil Society Organization, Health Care, Social Care
-
How did older people participate?
Older people were not directly involved
Lessons learned
-
Please describe how collaboration worked in your initiative.
Scientific societies and the central government
-
What was the impact of your initiative on older people, their families, and/or their communities?
In 2018, this service was launched, starting with a coverage of 39.3% of the target population included, which increased to 41.5% in 2019.
-
What issues did you face, and how did you address them?
in 2020 the coverage of the service was of 25% and in 2021 was of 21% due to COVID, but it is raising up again.
-
What lessons did you learn from implementing this initiative?
1) Health promotion and prevention is important in the elderly. 2) Care must be individualized according to needs. 3) Autonomy can be maintained, frailty can be prevented
-
Do you have any other reflections you would like to share?
N/A