DESK REVIEWS | 04.07. Dementia care coordination

DESK REVIEW | 04.07. Dementia care coordination

There is no mechanism in government to coordinate care specifically for people living with dementia. However, there is the National Policy for Primary Care (Política Nacional de Atenção Básica) that includes the Family Healthcare Strategy (a multidisciplinary team of health professionals that provides regular care to the community). These groups are the first point of contact between people in the community and the provision of public healthcare (Brazilian Ministry of Health, 2012). Based on a multidimensional assessment, people are referred to more specialized care where they can access diagnoses and treatments when needed. There is also a programme/service called “Matriciamento em Saúde Mental” which is a model of delivering healthcare where two or more professional teams create a proposal of a pedagogical-therapeutic intervention. In Brazil, this model is developed between the Family Health Strategy (reference team) and a supportive mental health team (in the case of dementia). The aim is to make the system less hierarchical by providing a specialized technical support to an interprofessional team so as to broaden their field of action and to qualify their actions (Brazilian Ministry of Health, 2011b).

References:

Brazilian Ministry of Health. (2011b). Guia prático de matriciamento em saúde mental. http://bvsms.saude.gov.br/bvs/publicacoes/guia_pratico_matriciamento_saudemental.pdf

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica. http://189.28.128.100/dab/docs/publicacoes/geral/pnab.pdf

 

PERDOSSI recommends care pathways that enable people with dementia (and their families) to have access to assessments through multidisciplinary teams as well as to psychosocial interventions. It is recommended that each patient suspected to have dementia at primary care level should be referred to the specialistic/secondary level of healthcare (neurology/psychiatry/geriatrics) or a memory clinic. Memory clinics should have multidisciplinary teams including neurologists, psychiatrists, geriatricians, psychologists, nurses, occupational therapists, physiotherapists, and (additional) general practitioners, home care workers, nutritionists, social workers, speech therapists, pharmacists, and local Alzheimer group representatives. The guideline does recommend one care provider to be the key care coordinator (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Similar to mental health care, dementia care is not well integrated within health care delivery systems. Mental health care, which also covers dementia care is only provided in 29 of the 284 Level 4 hospitals and above but only few hospitals have a multidisciplinary team (psychiatric nurses, social workers, psychologists and medical doctors). There is also no structured needs assessment on the person with dementia and the caregiver. Often, the first point of entry is the outpatient clinic where a doctor gives a diagnosis and recommends referral to a psychiatric nurse for further psychosocial management after pharmacological and non-pharmacological prescription by the doctor. A care plan is then developed by the nurse or the psychologist rather than with the patient (focus group discussion with health care workers through the STRiDE project). There are no documents illustrating the existence of this process.

As mentioned above, there are no national dementia policies and no care coordination mechanisms are in place.

There is no coordinated planning nor resourcing of care specifically for people living with dementia in Brazil. What we have that may be closer to a coordinated care is the “Matriciamento em Saúde Mental” (cited above), that could include health and educational sectors from below.

Care for people with dementia is provided in both, the public and private sector. The public sector is overseen by the Ministry of Health. However, there is no coordinated care across the two sectors as people who access public health care (often free or subsidized) may not be able to afford private health care. Those accessing private health care in turn may consider public health care as sub-standard or as a service that does not pay particular attention on patient needs.

No data is available as no care coordination mechanisms are in place.

The Ministry of Health is involved in coordinating care for all health issues. Its mission is “to build a progressive, responsive, and sustainable health care system for accelerated attainment of the highest standard of health to all Kenyans” (Ministry of Health, 2019). Dementia care activities are included within the health sector.

References:

Ministry of Health. (2019). About the Ministry. https://www.health.go.ke/about-us/about-the-ministry/

The Ministry of Labour and Social Protection is involved in coordinating social protection schemes for vulnerable populations e.g., persons with severe disabilities and older persons aged 65 years and above (Ministry of Labour and Social Protection, 2019b). These schemes are not specifically for persons with dementia but cover this population e.g., older persons who are an increased risk of having dementia and persons with a disability like dementia.

References:

Ministry of Labour and Social Protection. (2019b). Social Assistance Unit. https://www.socialprotection.go.ke

The Kenyan private sector is one of the most developed sectors in Sub-Saharan Africa. 47% of the poorest quintile of Kenyans use a private health facility (Marek et al., 2005). The private sector Partnerships – One project (PSP-One) conducted an assessment of the private sectors in Kenya and revealed a potential for this sector in providing quality care to Kenyans (Barnes et al., 2010). For example: One third of couples obtain their family planning methods from the private commercial sector and another 10 percent go to facilities run by non-governmental organizations (NGOs) and faith based organizations(FBOs) (Barnes et al., 2010). The public private partnerships and funding in this area shows the involvement of the private sector in planning for health care including policy development. Although not specific on dementia, there are already strides towards achieving government-private partnership in health which covers dementia.

References:

Barnes, J., O’Hanlon, B., Feeley, F., McKeon, K., Gitonga, N., & Decker, C. (2010). Private Health Sector Assessment in Kenya. 193(1). Washington, D.C. https://openknowledge.worldbank.org/bitstream/handle/10986/5932/552020PUB0Heal10Box349442B01PUBLIC1.pdf?sequence=1&isAllowed=y

Marek, B. T., Farrell, C. O., Yamamoto, C., & Zable, I. (2005). Trends and Opportunities in Public-private Partnerships to Improve Health Service Delivery in Africa. Human Development Sector Africa Region, The World Bank. https://documents1.worldbank.org/curated/en/480361468008714070/pdf/336460AFR0HDwp931health1service.pdf

Considering the “Matriciamento em Saúde Mental”, it is at national level.

The National Dementia Plan coordinated planning at the national level (Ministry of Health Republic of Indonesia, 2015b). In the recently drafted National Plan of Older People’s Health 2020-2024, the action plan draft also describes roles of the sub-national level government institutions (provincial, city, Kecamatan levels).

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.

There is no document describing the current practice on dementia.

No data is available as no care coordination mechanisms are in place.

We could not find an answer for this. It seems that the topic has gained some attention among intersectoral working groups as the law for the dementia plan has been approved by the Senate. It is likely that, at some point, formal agreements and joint plans have been established for the implementation of the policy. Besides, it is possible to observe communication across sectors regarding policies to older people in general.

The national strategy document declares the stakeholders across sectors responsible for providing care for people with dementia. Although the development of this document was led by the Ministry of Health, it supposedly serves as a joint plan. However, there is no care coordination pathway across sectors for dementia that can be found in this document (Ministry of Health Republic of Indonesia, 2015b). In the recently drafted National Action Plan of Older People’s Health for 2020-2024, the action plans and indicators are described along with the responsible stakeholders, and this will serve as an additional joint plan to the National Dementia plan document.

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.

There are no formal agreements.

No data is available as no care coordination mechanisms are in place.

No data is available as no care coordination mechanisms are in place.

There is an interdisciplinary team (psychiatric nurses, social workers, and psychologists) in some level 5 hospitals especially those with a mental health clinic. However, there is uncoordinated planning and weak monitoring and evaluation systems at both National and County levels which worsen in lower levels of care (John & Kiarie, 2019).

References:

John, T., & Kiarie, H. (2019). Building strong stewardship and collaborating systems towards UHC in Kenya’s Devolved Health system. Nairobi, Kenya.

Due to shortage of human resources and funding for mental health care, the current component of care coordination is often task-sharing (facilitated by NGOs). For instance, Africa Mental Health Research and Training Foundation has implemented task sharing approaches through training non-mental health specialists (nurses, clinical officers) to provide interventions to people with mental illness (including dementia) receiving care in primary health care facilities and community providers such as community health workers, traditional, and faith healers to identify and refer people with suspected mental illness for further care (Mutiso et al., 2018).

References:

Mutiso, V. N., Gitonga, I., Musau, A., Musyimi, C. W., Nandoya, E., Rebello, T. J., … Ndetei, D. M. (2018). A step-wise community engagement and capacity building model prior to implementation of mhGAP-IG in a low-and middle-income country: a case study of Makueni County, Kenya. International Journal of Mental Health Systems, 12(1), 1–13.  https://doi.org/10.1186/s13033-018-0234-y

It was not mentioned whether there are provisions to ensure provider continuity (e.g., for a patient to be seen by the same GP at every visit).

The Kenya Mental Health Policy states that individuals, families, and communities will play a key role in promotion, prevention, treatment, and rehabilitation of persons with mental disorders. They will also participate and advocate for community mental health programmes (Ministry of Health, 2015c). This community-based approach involves dementia care.

References:

Ministry of Health. (2015c). Kenya mental health policy 2015-2030: Towards Attaining the Highest Standard of Mental Health. Nairobi, Kenya. https://publications.universalhealth2030.org/uploads/Kenya-Mental-Health-Policy.pdf

Yes, if we consider the “Matriciamento em Saúde Mental” care coordination occurs at all levels, but it is coordinated by the primary level of care.

Yes, it is expected at all levels. Care coordination involving a multidisciplinary team is expected to be provided at the secondary and tertiary level of healthcare facilities, covered by the universal healthcare scheme. All these healthcare facilities are subject to the central government’s regulations. However, the National Dementia Plan encourages capacity building programmes to medics and non-medics to be emphasised in the primary care level (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.

There is uncoordinated planning and weak monitoring and evaluation systems at both National and County levels which worsen in lower levels of care (John & Kiarie, 2019).

References:

John, T., & Kiarie, H. (2019). Building strong stewardship and collaborating systems towards UHC in Kenya’s Devolved Health system. Nairobi, Kenya.

No data is available as no care coordination mechanisms are in place.

There is no specific care coordination for people living with dementia. In the cases of the “Matriciamento em Saúde Mental”, there is neither supervision nor referral, it is a system that works horizontally, so when the family health team needs support regarding education, group intervention related to mental health etc., the “matriciamento” team is requested (Brazilian Ministry of Health, 2011b). The process through which different health and social care services which are relevant for people living with dementia should be coordinated/integrated is detailed in policies led by the Ministry of Health (Brazilian Ministry of Health, 2002, 2018e).

References:

Brazilian Ministry of Health. (2002). Redes estaduais de atenção à saúde do idoso: Guia operacional e portarias relacionadas. Editora MS. http://bvsms.saude.gov.br/bvs/publicacoes/redes_estaduais.pdf

Brazilian Ministry of Health. (2011b). Guia prático de matriciamento em saúde mental. http://bvsms.saude.gov.br/bvs/publicacoes/guia_pratico_matriciamento_saudemental.pdf

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.

No information found regarding these aspects from the government’s perspective.

No data is available as no care coordination mechanisms are in place.