DESK REVIEWS | 04.03.09. (How) does the policy document support integrated care?

DESK REVIEW | 04.03.09. (How) does the policy document support integrated care?

Yes. The “Technical Guidelines for Implementing a Healthcare Pathway for Integral Health for Older People” is a document that supports integrated care in the Brazilian Unified Health System – SUS. This document explains that the government provides a “healthcare notebook” for older people, in which each older person should have her health information recorded. Based on this information, the person then becomes subject to a multidimensional assessment which considers physical, psychological, and emotional aspects of a person’s life in order to offer quality healthcare to each individual person. Based on these two tools, a “Person-Centered Therapeutic Plan” (Programa Terapeutico Singular – PTS) is tailored according to the needs and personal situation of each patient aiming at delivering integrated care, education, and better quality of life (Brazilian Ministry of Health, 2018e).

References:

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

The Mental Health Review Report (MHRR) proposes an integrated community care and intervention model for persons with dementia (Food and Health Bureau, 2017a, p. 171). It emphasises the need for bilateral and integrated support by health professionals in primary and specialist care for dementia. It recommends that medical-social collaboration should be enhanced to integrate the delivery of medical, community, residential, as well as psychosocial care services to provide patient-centred support and bring the best possible outcomes in dementia care in the long run (Food and Health Bureau, 2017a, pp. 175-180).

The Elderly Services Programme Plan (ESPP) proposes a recommendation that dementia should be integrated in the whole spectrum of elderly services and a multi-disciplinary approach should be adopted by especially with a closer collaboration between the healthcare system and welfare sector for dementia (Working Group on Elderly Services Programme Plan, 2017, p. 30).

References:

Food and Health Bureau. (2017a). Mental Health Review Report.  Retrieved from https://www.fhb.gov.hk/download/press_and_publications/otherinfo/180500_mhr/e_mhr_full_report.pdf.

Working Group on Elderly Services Programme Plan, Elderly Commission of Government of Hong Kong SAR,. (2017). Elderly Services Programme Plan. Hong Kong: Elderly Commission of Government HKSAR Retrieved from https://www.elderlycommission.gov.hk/en/download/library/ESPP_Final_Report_Eng.pdf.

The policy document states the target to implement standard operational procedures across all healthcare facilities. Furthermore, the document emphasises the standardization of instruments, the value of screening, diagnosis, and treatment of people with dementia in primary healthcare facilities and through appropriate referral to secondary and tertiary healthcare facilities. Secondary and tertiary healthcare services are expected to provide integrated geriatric services and neurorestoration services (Ministry of Health Republic of Indonesia, 2015b).

References:

Ministry of Health Republic of Indonesia. (2015b). National Strategy: Management of Alzheimer and Other Dementia Diseases: Towards Healthy and Productive Older Persons. Ministry of Health Republic of Indonesia.

No data was sourced due to a lack of dementia policy in Jamaica.

It emphasises the need for an integrated care model involving all levels of the national health system, as well as the development of a training, evaluation and care model for primary caregivers and family members. On the other hand, the document aims at generating an inter-institutional network for the updating and feedback of personnel dedicated to the care of the person with dementia.

NZ Dementia Framework:

One of the principles of the framework is for the “provision of accessible, proactive and integrated services that are flexible to meet a variety of needs”. It then goes on to describe an ideal integrated service such that:

  • service models are adapted to meet local needs and are supported by local and regional dementia care pathway governance structures,
  • care planning is consistent, coordinated, and flexible across all services (including DHBs, primary and secondary health care, government organisations, non-government organisations and private sector organisations), ensuring seamless continuity of care and support,
  • interdisciplinary assessment and care planning focuses on functional, psychological, and social goals,
  • gaps in services that cannot be filled locally are met by a sub-regional or regional approach,
  • the person with dementia’s care team is responsible for identifying a suitable navigator.

Dementia plan:

One of the guiding principles of the plan is integrated care where “all parts of the dementia sector work together in the implementation of the plan”. The action areas of the plan highlight the need for working collaboratively and for national cross-sector stewardship and leadership.

Not applicable as there is no dementia-specific policy or plan for South Africa.