Figure 1
Example of the care pathway of a 90-year-old in the French health system. Mr B is 90 years old. He lives alone at home with help from health professionals, but without family support, and is financially vulnerable. He suffers from severe osteoarthritis and from the sequelae of previous osteoporotic fractures. His mobility is very limited and he needs help in the activities of daily living. He also suffers from mild to moderate cognitive impairment and from macular degeneration.
a) Example of the care pathway of a 90-year-old in the French health system in 2010. In 2010, health professionals providing home care had little opportunity to collaborate and depended mostly on their regional health authority (regulated by the public health code) for the regulation of their activity. Social workers and housekeepers were mainly under the governance of the Territorial Authority (regulated by the Social Action and Family Code). Following emergency admission to hospital because of organ failure, the patient was in need of rehabilitation and, according to availability and the patient’s choice, was transferred to a private clinic near his home where his own general practitioner could attend to him. Following a subsequent complication, the patient was transferred to a university hospital, because there was no bed available at the previous clinic. Finally, the outcome was unfavorable and admission to a nursing home was considered. In this 2010 scenario, there was no continuity between the first-line medical team and the private, local, university hospital, and nursing home health and social professionals. In 2010, the policy concerning homes for the integration and autonomy of Alzheimer patients (MAIA) was being implemented, while introducing a shared information system (with training workshops during 2010), a joint assessment tool (idem), and the appointment to a new post of a supervisor who intervened wherever needed in the patient’s health trajectory so as to coordinate actions and respond to the patient’s priorities and care needs. Case managers can report to the supervisor (see text) if there is frequent or problematic fragmentation between the various organizations, and together they can report difficulties in health and social issues at strategic round tables led by the regional health authority.
b) Example of the care pathway of a 90-year-old in the French health system in 2020. In 2020, several mechanisms are being implemented to facilitate collaboration between the various health professionals of a given territory (multidisciplinary care homes, territorial professional health communities, and territorial coordination of support for the experimental scheme for the older people at risk of loss of autonomy). However, there are no training workshops for a shared information system or for joint professional and common assessment tools, and although there is some connection between the health and social authorities, there is no systematic round table discussion.
a The term “case manager” is used here to describe the professional function, but the name may vary.
Table 1
Evolution of integrated care in France between 2010 to 2020 according to a framework derived from a model described by Leutz and by Kodner et al. [7, 21].
| FACTORS | WHAT WAS THE SITUATION IN 2010? | WHAT WAS EXPECTED FOR 2020? | WHAT HAS BEEN IMPLEMENTED IN 2020? | WHAT IS EXPECTED IN THE NEAR FUTURE? |
|---|---|---|---|---|
| Funding mechanisms | Multiple sources of funding of health expenditures for older people Payment of healthcare provider on a fee-for-services basis | Pool funds to have a complete and transparent vision of health expenditures for older people Diversification of payment of care providers to encourage pathway coordination for older people | (–) No annual integrated complete vision of health expenditures for older people until 2020 (+) Introduction of capitation payment for GPs and quality-based payment for GPs and hospital | Implementation of a fifth “autonomy” branch of the social security system to cover all provisions of care and services relating to loss of autonomy in 2021 Development of innovative funding for care providers (development of financial incentives to quality of care for care providers, funding for care pathway) |
| Governance and management | National governance fragmented in the French Solidarity and Health Ministry Regional and local governance fragmented between regional health agencies and territorial councils | Integrated governance of health policies for older people from national to local level with strong national leadership | (–) Persistence of fragmentation at the national and local levels (–) Absence of integrated care concept references in regulations and laws (+) Implementation of health care democracy | Growing implementation of health care democracy |
| Jurisdictional boundaries and information-sharing | No legal framework to share information between care and social professionals | Creation of a new legal framework to allow sharing of files Joint record for social and health providers | (+) Lifting of the restrictions on information by the 2015 law on the adaptation of society to aging (–) No joint record for social and health providers | Repeal of the law on the adaptation of society to aging scheduled for 2022 |
| Quality of care and system outcomes | No systematic assessment of health policies for older people | Implementation of a clinical assessment tool allowing reporting of information | (+) Development of the consideration of patient-reported experience and outcome measures to improve the quality of care (–) No systematic assessment of health policies for older people | Development of the consideration of patient-reported experience and outcome measures to improve the quality of care Development of innovative funding for care providers (development of financial incentives to quality of care for care providers, funding for care pathway) |
| Degree to which health and social care professionals collaborate, teamwork and continuity of care | Fragmentation between health, social, and medical-social sectors Gap between hospital and private practice in primary care | Shared responsibility for health status of the older people in a geographic area Shared responsibility for financial management for health and social care for older people in a geographic area | (+) Implementation of new care organizations: teams of primary care professionals (MSP), Territorial Professional Health Communities (CPTS) including health and social care providers from hospitals and private practice, Support Schemes for the Population and for Healthcare Professionals (DAC) facilitating integration in a geographic area (–) No shared responsibility for health or financial management for the health and social care of older people in a geographic area | Implementation by CPTS of a population-based approach |
| Patient screening and multidisciplinary assessment | No shared tool for patient screening and multidisciplinary assessment of loss of autonomy | Common tool sharing with all health and social care provider for loss of autonomy assessment | (–) No national and shared tool for loss of autonomy assessment | No plan for a shared assessment tool |
| Care management | No case management system addressed to older people | An effective case management for older people in complex situations performed by the MAIA | (+) Implementation of case management with the deployment of MAIA (–) Lack of legitimacy of case managers due to persistent fragmentation (case managers have no delegation of power to initiate services that seem necessary) (+) Multiple innovative organization to optimize older people’s life pathway | Structuring and coherence of the multiple innovative organization to optimize older people’s life pathway |
[i] CPTS: Territorial Professional Health Communities called in French “Communautés Professionnelles Territoriales de Santé.” MSP: Group of self-employed healthcare professionals called in French “Maisons de Santé Pluri-professionnelles.” MAIA: Method of Action for Integration of Health and Social Care in the Field of Autonomy, called in French “Méthode d’Action pour l’Intégration des services d’aides et de soins dans le champ de l’Autonomie.” DAC: Support schemes for the population and for healthcare professionals in coordinating complex care pathways called in French “Dispositifs d’Appui à la Coordination et aux professionnels pour la coordination des parcours de santé complexes.” GP: general practitioner.