Integrated Care for Older People in France in 2020: Findings, Challenges, and Prospects

Abstract

Background: We analyze here major changes over the last decade in the French healthcare system for older people, in terms of the integrated care concept.

Policies: During this period, the major theme of public policies was "care coordination." Despite some improvements, the multiplication of experimental programs and the multiplicity of stakeholders distanced the French healthcare system from an integrated care model. Professionals and organizations generally welcomed these numerous programs. However, most often, the programs were insufficiently implemented or articulated, notably at a clinical level, because of the persistence of a high level of fragmentation of governance, despite the creation of regional health agencies 10 years ago. The COVID-19 crisis has highlighted this fragmentation. Moreover, we still lack data on the impact of these programs on people's health trajectories and personal experiences.

Conclusion: The French healthcare system seems more fragmented in 2020 than in 2010, despite improvements in the culture of professional collaboration. The future health reform is an opportunity to capitalize upon this progress and to implement "integrated care." This implies a strong and continuous national leadership in governance and change management.

Keywords: France; gerontology; health and social integration; older people.

Figure 1

Example of the care pathway of a 90-year-old in the French health system. Mr B is 90 years old. He lives alone at home with help from health professionals, but without family support, and is financially vulnerable. He suffers from severe osteoarthritis and from the sequelae of previous osteoporotic fractures. His mobility is very limited and he needs help in the activities of daily living. He also suffers from mild to moderate cognitive impairment and from macular degeneration. a) Example of the care pathway of a 90-year-old in the French health system in 2010. In 2010, health professionals providing home care had little opportunity to collaborate and depended mostly on their regional health authority (regulated by the public health code) for the regulation of their activity. Social workers and housekeepers were mainly under the governance of the Territorial Authority (regulated by the Social Action and Family Code). Following emergency admission to hospital because of organ failure, the patient was in need of rehabilitation and, according to availability and the patient’s choice, was transferred to a private clinic near his home where his own general practitioner could attend to him. Following a subsequent complication, the patient was transferred to a university hospital, because there was no bed available at the previous clinic. Finally, the outcome was unfavorable and admission to a nursing home was considered. In this 2010 scenario, there was no continuity between the first-line medical team and the private, local, university hospital, and nursing home health and social professionals. In 2010, the policy concerning homes for the integration and autonomy of Alzheimer patients (MAIA) was being implemented, while introducing a shared information system (with training workshops during 2010), a joint assessment tool (idem), and the appointment to a new post of a supervisor who intervened wherever needed in the patient’s health trajectory so as to coordinate actions and respond to the patient’s priorities and care needs. Case managers can report to the supervisor (see text) if there is frequent or problematic fragmentation between the various organizations, and together they can report difficulties in health and social issues at strategic round tables led by the regional health authority. b) Example of the care pathway of a 90-year-old in the French health system in 2020. In 2020, several mechanisms are being implemented to facilitate collaboration between the various health professionals of a given territory (multidisciplinary care homes, territorial professional health communities, and territorial coordination of support for the experimental scheme for the older people at risk of loss of autonomy). However, there are no training workshops for a shared information system or for joint professional and common assessment tools, and although there is some connection between the health and social authorities, there is no systematic round table discussion. ^a The term “case manager” is used here to describe the professional function, but the name may vary.