Addressing the needs of people over the age of 65 in Grudziadz (Poland): a model for a local integrated care solution

Abstract

Due to the growing demand, as well as their rising unit costs, services for the elderly are becoming an increasing burden on the budget of the health and social system. An assessment of the needs of the elderly in Grudziadz was carried out by us at the beginning of 2019 using quantitative and qualitative methods. The objective of these analyses was to tailor proposed solutions to the needs and aspirations of Grudziadz community as well as provide on-time solutions to real problems. Based on that we have proposed a model of coordinated care for persons above 65 in Grudziadz, which includes 4 main components: 1. Establishment of the Senior Citizens' Office - a unit dealing with the planning, coordinating, monitoring and supporting health and social data gathering 2. Establishing the function of an elderly care coordinator – within the primary health care facilities, in cooperation with other facilities providing local and regional care for elderly 3. Regular assessment of the health, well-being and independence status of elderly people, for the purpose of determining the scope and type of necessary care/assistance and provision of care plans accordingly to the assessed needs. 4. Introduction of mechanisms of information transfer between health care and social assistance institutions about the state of health, needs and available services for elderly people