A model of integrated care for people with dementia in Primary Care

Andrea Fabbo, Oreste Capelli, Maria Luisa De Luca, Luc Pieter De Vreese, Monica Pini, Lara Rovesta, Valentina Solfrini, Cristina Marchesi
2014 International Journal of Integrated Care  
In the last years some RCT have demonstrated the efficacy of "integrated models of care" in the management of chronic diseases such as depression and dementia. Since 1999 the Regional Government of Emilia-Romagna deliberated the "Regional Dementia Project" (D.G.R. 2581/1999) , an act that provides funds for the organization of Health and Social Welfare services in the community for people with dementia. The main strategies and tools of Dementia Project are: a) ensure good and timely diagnosis;
more » ... timely diagnosis; b) global approach to PWD and his familiy (social and healt services integrated); c) qualify existing network service (not only separate net for PWD); d) improve and support caregivers The design includes specialized out-patient clinics with competencies for diagnosis and care planning. A targeted project of the Public Health Agency of Modena has been implemented to involve the family physician in dementia screening and followup, by means of accreditation courses, promotion of uniform screening instruments and structured annul following up of the patients with epidemiological reporting; the family physician is seen as pivotal in providing a continuum of care over the long natural history of the disease. The main outcome of this agreement is to improve the quality of life and health of demented individuals and their carers, permitting people with dementia to remain at home as long as possible, and to promote the management of dementia patients by the primary care physicians (PCP). The specialized referral clinics offer diagnostic competencies and consult for specific problems. The protocol consists of two phases: in the first phase, when the PCP suspects a diagnosis of dementia, he/she administers simple, standardized screening tests, such as the Symptom of Dementia Screener (S.D.S.) and provides an assessment of somatic morbidity and functional
doi:10.5334/ijic.1868 fatcat:dtgurnn52fhlvn2ir5445mv6ue