The great majority of adults with multi -morbidities are the elderly people . The building of a community health care infrastructure for them is a new imperative of health systems.,

The development of an efficient geriatric community health care is a complex challange. We should bear in mind that it is a secondary ] consultative service ,

not one that should provide emergency solutions . Primary care should remain in the hands of the primary physicians and their knowledge in basic geriatrics and how to cope with multi-morbidities and chronic disabilities should be strengthen. These are the 2 basic principles that should guide the development of the modern community primary care service.

From a diabetes perspective - we are offering annual check ups for older adults with and without diabetes and are implementing an all-in-one approach, which includes eye disease, heart disease, peripheral vascular disease, renal disease and cognitive impairment as well as depression. Any findings we have are then passed on to the primary care physician to address. We find that an all-in-one solution for multi-comorbidities is an important resource in the community as it provides an alternative for people to seek medical information without having to visit their general practitioner.

Thank you Robert for referring and uploading these papers on community care. One question or observation I have is that these multicentre trials do not translate into community care effectively - at least not in the rural Australian context. One contentuous issue is the primary care field where physicians are already overloaded with patients and current models are looking into allied health for instance to close the gap.

The community based models or the integrated models differ from country to country depending upon their needs. For ex, the model works efficiently in USA may not work in India and viceversa. Community care all together is a complicated topic with variations. Come out with your own models. lalitha kabilan

We have in Egypt certain geriatric specialized center for primary, secondary and tertiary care delivered in the same place but still need more training of personnel and adequate managing of resources. We started as well some community based geriatric care private organizations, owing to the rapidly growing Egyptian elderly population living with multiple comorbidities. The integrated model of care, I think, need a collaborative approach in geriatrics care involving community, acute hospital and rehabilitative care in a multidisciplinary system.

What should a health system do in order to iaddress the increasing health care needs of the the elderly population ? Education , meaning , Geriatric Medical Education is the key for a better geriatric care,

The WHO recomended an epidemilogic approach to the issue of how to

cope with the ageing of the population. This should be supplenmented by the

rcognition of geriatric medicine as a distinct medical speciality. These are the

necessary seeds for the growing of a modern heathcare system for the elderly.

What is even more important is, to include obligatory geriatric teaching in all the curiculla of medical students ,nursing study programs and health professions like speech therapy ,nutrition, physiotherapy and occupational therapy.

Likewise 'primary care physicians should be initiated in the basics of geriatrics at a level that will provide a better approach to elderly chronic persons with multi-morbidity. The most needed issue ( based on our experience ) is that of the

rational use of drugs in the elderly!

In parallel the media should assume the task of presenting the issue of health care for the elderly to the public and generate discussions about it. All these will put the care for the elderly on the table and will ensure a considerable progress in a few years,.

Here in Wales we have a case management approach, whereby District Nurses and Case managers (nurses with an advanced practice qualification - at Masters level) work within an intergrated team. But there are many variations of this still, and it is an evolving service. The services are targeted at those living at home with multiple morbidities. The model is a development of the 'Evercare' or Kaiser Permenante model. Try this address for the strategic approach being taken. I know it's dated, but there have been progress reports published on the net.

http://www.wales.nhs.uk/documents/serviceplane.pdf

Hi Kerry Kuluski

Perhaps these articles can help you:

1) http://jcomorbidity.com/index.php/test/article/view/21 

2) http://www.bmj.com/content/345/bmj.e5205

Best regards, Bruno.

The key is probably the " case manager"  which  , as mentioned above by Joanne ,

is now evolving . Pilot projects as to the responsabilities of this position will probably

give results and recomandations in about 5 years,