Problem: Increasing chronicity in an ageing population; lack of coordination between health and social sectors; fragmentation across different levels of care.
Solution highlights: The Ministry of Health and Social Affairs opened the Gerontology Coordination Centre as a dedicated resource to support and provide services to elderly people aged 60 years and over; Monaco's small geographic and population size lent itself to a centralized approach. The initiative created a hub for the coordination of multiple aspects of health and social care for the elderly; services offered by the Centre are holistic, integrated, tailored to individual needs and place strong emphasis on supporting patients’ independence. Comprehensive geriatric assessments evaluating physical, mental and social needs are now available to all people aged 60 years and over; data collection performed by the Centre provides information on emerging needs within the elderly population, enabling data-driven policy responses.
Description of practice
Monaco faces an increasing burden of chronicity in an ageing population, straining the ability of health and social services to manage the increasingly complex needs of elderly patients. While both the health and social care sectors were well established, a lack of coordination and information sharing between them hindered their effective functioning. Furthermore, fragmentation across care levels obstructed smooth transitions between inpatient, outpatient and home care services and compromised continuity of care for patients.
In 2005, understanding that effectively addressing the needs of an ageing population called for a more coordinated approach to health and social care, the Ministry of Health and Social Affairs worked with a multistakeholder group to analyse demographic data, define gerontology concepts and develop a new structure for the coordinated delivery of health and social care for elderly people. As a result of these efforts, the government opened the Gerontology Coordination Centre in 2006 as a dedicated resource supporting elderly people aged 60 years and over. The Gerontology Coordination Centre serves as the central coordinator of health and social care for the elderly in Monaco and services are led by a multidisciplinary team including a geriatrician, nurses, social workers and a psychologist. As part of the Centre’s services, people aged 60 years or older are eligible to receive a comprehensive geriatric assessment designed to evaluate functional ability, physical and mental health and socioenvironmental circumstances. Assessments are conducted by the Centre’s geriatrician, with annual reassessments led by nurses in home settings. Personalized care plans designed to promote good health and support independent living are then developed by the multidisciplinary care team based on individual assessment results and are reviewed with patients in their homes. Depending on the financial resources of patients, necessary care costs may be covered by the government. In addition to coordinating and delivering services directly to patients, the Centre also has important public health functions including the collection and evaluation of health data to help identify national health trends and emerging needs within the elderly population. Information collected by the Centre is used by the Ministry of Health and Social Affairs to implement policies supportive of healthy ageing and to develop a more favourable environment for elderly citizens. Presently, the Centre continues to serve the elderly population in Monaco and advise the government on health and social care needs for this population group.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Development and implementation of the initiative was led by the Ministry of Health and Social Affairs. A new multidisciplinary team was formed to oversee the running of the Gerontology Coordination Centre. Under supervision from the Ministry, this team continues to manage the Centre and provide care for the elderly population in Monaco today. Led by an administrative coordinator, other members of the team include a secretary, geriatrician, nurses, social workers and a psychologist. Partnerships with other actors, such as general practitioners, hospital specialists and elderly care home providers, ensure the Centre is connected to all key stakeholders. Weekly team meetings between Centre staff facilitate the smooth running of the Centre and serve as an opportunity to discuss emerging needs and set future objectives.
Since opening, the Centre has performed 4675 geriatric assessments and attended to the needs of 2100 patients. Closer follow-up of elderly patients as a result of the Centre has reportedly delayed the need for institutionalization by up to eight years.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Anne Negre
- Ministry of Health and Social Affairs