Predominantly primary care based interventions

discharge telephone calls and home visits. The programs may be directed at the individual patient (57) or at groups of patients with the same condition (58, 59). In Norway patient education is a hospital duty (60), but generic self-management programs have also been developed in primary care addressing patient with different chronic diseases (61). Best effect seems to be when self- management and educational programs are part of multi-component discharge support to groups of patients with single diseases (37, 62).

2.2.2 Predominantly primary care based interventions

The overarching goal of primary health care strategies addressing elderly patients is to maintain health and autonomy and to prevent disability and subsequent admissions to long-term institutional care (63). To achieve this, several strategies aim to improve post-discharge follow-up (36, 64) as well as to coordinate health and social care providers in the municipalities (26). This includes transitional care units in primary care for patients being discharged from hospital, multidisciplinary teamwork, chronic care models, patient-centred medical home, and interventions aiming at improving functional ability and support self-care. These strategies are presented in further detail below.

Transitional and intermediate care units based in primary care have been developed to ensure sufficient post-discharge support to elderly, frail patients when hospital stays become shorter (4, 65-68).The purpose is to fulfil medical treatment, observe, mobilise or rehabilitate the patients before they return to their own homes (20, 68). Intermediate care units have documented a potential of reducing readmissions to hospital, increase survival and independence (4, 5). However, such arrangements further increase the fragmentation in primary care by representing a new link in the chain of care. In Norway, the Coordination Reform has also introduced 24/7 municipal emergency bed services in primary care as an alternative to hospital admissions (69, 70). The target group is mainly elderly patients with acute illnesses or exacerbation of chronic illnesses who have become too ill to be treated at home, but yet not in need of specialised health care services in hospitals (7). The effect is debated, but there is some evidence that acute treatment at intermediate level to suitable patients do not lead to negative health

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consequences (71) and slightly reduce the number of readmissions to general hospital provided close follow-up by primary care physicians (70).

Multidisciplinary teamwork is a strategy increasingly brought forward as a means to coordinate health care services for elderly and chronically ill patients in primary care (72, 73). It represents one of the main measures in a Norwegian White Paper from 2015 on future primary healthcare (74). The Norwegian White Paper suggests the GP practices supplemented by nurses to be the core of multidisciplinary teams. However, such teams may be composed of a range of health care professionals functioning under one professional organisational umbrella or by professionals from different

organisations forming a unique team for follow-up of individual patients with complex conditions (73). An example of effective multidisciplinary teamwork is found in a Danish study where GPs and home care nurses provided joint comprehensive follow-up to elderly patients during the first weeks after hospital discharge, achieving improved patient level outcomes and reduced health care utilisation (75). In Italy,

multidisciplinary teams have been organised in geriatric evaluation units (GEU) in primary care. These are coordinated by a geriatrician and otherwise including community based home care nurses, social workers and physiotherapists in close collaboration with the patient’s general practitioner. The GEUs are addressing elderly persons receiving home health care services or home assistance programmes and have documented effect in reducing functional decline, reducing the risk of hospital

admissions, and reducing the length of stay in hospitals or long-term institutional care in the municipalities (76, 77). Involvement of the GPs is found to be a necessity in well-functioning multidisciplinary teams (78). Still, GP involvement has been a recurring challenge, described in Nordic countries and Canada, as GPs consider teamwork to be too time consuming, their role has been unclear, and they have been reluctant to take the responsibility expected of them in the teams (72, 79).

In the chronic care model (CCM) the focus is on chronic care management, primarily in GP practices, by transforming care from acute and reactive to proactive and planned (80, 81). CCM was initially developed in the United States, but has spread to countries worldwide. The components of a chronic care model have varied across different sites,

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but the main strategies of CCM include increasing the providers’ knowledge and skills, supporting self-management of patients and their families, making care delivery more planned and team-based , and making better use of decision support and clinical information systems (82). Studies suggest that implementation of CCM improves the outcomes for patients with various chronic illnesses. However, redesigning the practice in accordance with CCM is comprehensive and requires highly motivated practices. In most cases, CCM has been applied on patients with a single chronic condition, diabetes mellitus being the most common (81). There is limited evidence on whether practice changes become sustained and spread to the care of other illnesses or to less motivated practices (82).

The patient-centred medical home (PCMH) is a measure to redesign primary health care from highly fragmented and uncoordinated to continuous, comprehensive and

coordinated medical care of high quality. The model is developed in the United States and the precursor, ‘medical home’, was first used in 1967 by the American Academy of Paediatrics to ‘describe a concept of a single centralised source of care and medical record for children with special health care needs’ (83). PCMH has a patient-centred orientation towards the whole person. Care is to be coordinated across all health care levels and health care providers, including also preventive and health promoting activities in the patient’s community. As in the CCM model, care is to be team-based (83, 84). CCM and PCMH is partly overlapping concepts, but while the PCMH model describes what patients should expect and how the practice can meet those expectations, the CCM model describes how care should be structured and delivered (85).

Preventive home visits have received much attention the last decades and have been part of national policy in several countries, including Denmark, UK, and Australia, as a measure to prevent functional decline and premature admission to long-term

institutional care (86, 87). Some programs focus on one risk factor like e.g. falls (88).

Others include multidimensional geriatric assessment to assess and improve medical, functional and social problems and resources (63, 88, 89). Multidimensional

assessments with clinical examinations are found to have a potential of preventing functional decline, first and foremost among the elderly population at low risk of

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functional impairment. For patients with high risk of impairment, intensive, long standing home-based intervention program focusing primarily on improving underlying impairments in physical abilities has been found to be necessary to reduce functional decline (90). Yet the scheme for preventive home visits is debated, as they tend to be resource-demanding interventions, and as it proves difficult to identify what

distinguishes effective programs from ineffective programs on mortality and institutionalisation (88).