出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Life expectancy has increased globally from 64 to 71 years. For many elderly people, hospitalization is followed by a fast decline of capacities and great mental challenges1. This progressive decline of the oldest age groups after hospitalization has triggered an increase in the prevalence of specific health and social conditions. Among these conditions, loneliness and cognitive impairment have been revealed among the most important causing dependency and re-hospitalization in elders2. In order to effectively address these issues, identifying frail elderly patients after hospitalization, and providing them with home-based care to fulfil their needs, may help to reduce readmissions at hospital facilities, and, thus, contribute to the sustainability of care systems as ultimate goal. Methodology – Intervention description : The intervention presented follows a holistic approach to hospital-at-home care, including the care of medical, social and psychological needs for elders. The intervention programme presented in this study targets older people aged 75 and above, who have been admitted at the hospital through the emergency department, and it starts after discharge from hospital to hospital-at-home. The programme is designed based on evidence, and is aimed to: 1 reduce loneliness and increase social participation; and 2 slow down the progressive cognitive impairment. As part of the intervention, the following care pathways are designed in order to complement the medical treatment and achieve the proposed aims: A motivational-based care pathway developed by social workers. This care pathway is intended to motivate the patient to take part in the community, based on patient’s personal likes, being the ultimate goal to reduce loneliness. The planned structure for this care pathway is a monthly face-to-face interview and telephone follow-up, in which the patient and the social worker check the accomplishment of a set of objectives and measures they have agreed-upon. A cognitive impairment care pathway guided by psychologists. This care pathway is based on attention and memory training for those patients suffering from mild cognitive impartment. The training is delivered using a workbook including a set of exercises to train cognitive strategies. The planned structure for this care pathway is performed by a psychologist by means of a face-to-face interview and two telephone interviews per month. Conclusion : The proposed intervention programme follows a population-oriented approach focus on each patient needs. The two care pathways on which this programme is based on provide a complementary intervention to medical care, ensuring that psychological and social aspects are also covered as a part of holistic healthcare delivery. This intervention offers an innovative care strategy of integrated care for those patients receiving hospital-at-home care. References : 1- Hengartner MP, Klauser M, Heim G, Passalacqua S, Andreae A, Rössler W, et al. Introduction of a Psychosocial Post-Discharge Intervention Program Aimed at Reducing Psychiatric Rehospitalization Rates and at Improving Mental Health and Functioning. Perspect Psychiatr Care. 2017 Jan 1;531:10–5. 2- Boaz TL, Becker MA, Andel R, McCutchan N. Rehospitalization risk factors for psychiatric treatment among elderly Medicaid beneficiaries following hospitalization for a physical health condition. Aging & Mental Health. 2017 Mar 4;213:297–303.
关键词：integrated care ; elderly people ; loneliness ; cognitive impairment
