How to assess the level of dependency in an integrated health care system. The andorran experience

Background: Disability becomes increasingly common with advancing age. Physical medicine and rehabilitation (PMR) aim to enhance the functional ability and decrease dependency and disabilities. In Andorra, there is a genuine dependence classification called Grau de Dependencia Andorra (GDA), which rates 0 (no dependence) to 5 (total dependence). It is used to allocate therapeutic and economic resources at the national public skilled nursing facility (El Cedre). To improve patient experience and achieve greater efficiency from health system (integrated care), this paper aims to reevaluate the actual level of dependence of people staying in El Cedre with several validated scales. Moreover, this study aims to measure patient's dependency against GDA levels and to provide the rehabilitation resources needed for improved healthcare. Methods: We conducted a cross-sectional descriptive study in which a PMR physician evaluated all residents using a functional dependence scale (Barthel Index), a cognitive impairment scale (Pfeiffer test), assessment of independent living skills (Lawton instrumental activities of daily living scale), and assessment of gait dependence (Rankin modified scale score and functional ambulation classification). In addition, patients underwent a physical musculoskeletal examination. The residents, their relatives, and the staff, including the rehabilitation team, were part of the assessment. Results: We evaluated 143 patients (120 inpatient and 23 in day hospitals) of which 48 were men and 95 were women. Considering previous GDA classification, almost 70% of patients had at least high dependence. However, there are no data specified on which kind of disability patients were suffering from. Comparing PMR evaluation to GDA results, we found no correlation between GDA level and rehabilitation requirements. As a result, we adapted groups to differentiate those participants with predominantly cognitive impairment from those with mostly physical impairment. We identified more than a half of participants (52.4%) suffering from cognitive impairment in comparison with the 19.5%, whose main disability came from physical impairment. The vast majority (72.02%) had moderate-to-high disability. Furthermore, up to 61.55% needed one or more people to walk. Results were reported to hospital executive department, assisting with El Cedre's management. Conclusions: PMR evaluation in a skilled nursing facility resulted in a change in allocating therapeutic resources, establishing properly the rehabilitation goals. To entirely evaluate disability, it is necessary to use both instruments of cognitive and physical assessment.