From a national program to local implementations: how to coordinate patient-centred care for elderly taking territorial specificities into account

Introduction : In the context of an ageing population and very fragmented health and social care systems, the French ministry of Health is testing a national program since 2013. It aims to tackle challenges faced at all levels: how to coordinate care pathways for elders at risk of losing their autonomy? We'll focus on the implementation of organisations supporting coordination of health and socialcare professionals around the patients and caregivers, at a territorial level. Practice change implemented  For each territory, implementation of: - A single organization accessible for professionals, patients and caregivers; - A unique phone number; - One information system; - New roles and responsibilities. Aim and theory of change : The program aims to: Avoid breaks in elderly care pathway; Improve quality of life of elderly and their caregivers, by reducing hospitalisations, time spent in hospitals, and improving care conditions; Orient professionals’ practices and create favorable conditions towards more coordination, cooperation and cross-cutting practices. Targeted population and stakeholders : Targets: elderly from 75 year old and above, at risk of losing their autonomy. Stakeholders: regional authorities, local social insurance organisms, professionals’ representatives unions, professionals and coordination actors, the ministry of health. Timeline : The program was launched in 2013. A first wave of 9 pilot’s territories was implemented in 2015. A second was launched in 2014 with 9 other territories. The program is ending in December 2018. Highlights : General objectives and framework are coupled with needs assessments, diagnostics and roadmaps elaborated by territorial actors. This is a key lever for embedding multiple actors who were, and still are, used to work in silos. It also helps formalizing already existing coordination and cooperation. Significant impacts on health outcomes have not been identified yet, as the program is too recent. However, a national evaluation confirms the needs of professionals to be supported, interest for transition management between settings and highlights valuable new roles focused on care coordination for patients and caregivers. Sustainability : All coordination organizations are now enshrined in law since 2016. The ministry displays a strong willingness for convergence and mutualisation of what already exists. At all levels, professional’s practices are encouraged to evolve towards more cooperation and shared practices. Transferability : The program offers a flexible framework for action, enabling implementations taking into account territorial specificity and context. It is customizable enough to permit appropriation by actors, and generalize these initiatives. Conclusions : Several recommendations can help stakeholders better organize their services by identifying: success factors in the running of projects; Levers improving responses related to accessibility, scheduling, coordination or implementation in a territory; Levers supporting a continuous improvement process based on a relevant assessment of implemented actions. Discussions : The program relies on a holistic and participative approach taking into account territorial specificities, but also the complex problematic the Ministry aims to tackle. The program achieved to embed professionals and change positively their way of working: information sharing, better knowledge of services delivered, capacity of mobilising various experts around the patients, implementation of new solutions, etc. Lessons learned : An impact evaluation is planned for end of 2018.