main topic
Wien Klin Wochenschr (2019) 131:273–277
https://doi.org/10.1007/s00508-019-1512-7
Pilot study of an integrated care model using the geriatric
assessment tool
Ariana Bytyci · Genc Ymerhalili · Thomas Ernst Dorner · Katharina Viktoria Stein · Osman Maxhera
Received: 18 February 2019 / Accepted: 2 May 2019 / Published online: 21 May 2019
© Springer-Verlag GmbH Austria, part of Springer Nature 2019
Summary
Background Older people with type 2 diabetes melli-
tus often suffer from adverse medical and social con-
ditions which are often unrecognized in routine care.
Integrated care aims to address all these aspects and
centers on the needs of the patient and not the dis-
ease. The Accessible Quality Healthcare project in
Kosovo, is piloting an integrated care model for pa-
tients 65 years and over with type 2 diabetes mellitus,
which also introduces comprehensive geriatric assess-
ment and care planning.
Methods In this study two groups (1) a central working
group and (2) a multisectoral implementation group
of health and social care professionals were estab-
lished to develop a geriatric assessment form and an
individual care plan form for this project.
Results The groups decided to address the follow-
ing problems in the geriatric assessment: activities of
daily living, urinary incontinence, gait, balance, falls,
depression, cognitive function, and frailty. The assess-
ment is carried out by a nurse and a social worker in
the living environment of the patient, and the individ-
A. Bytyci () · G. Ymerhalili
Accessible Quality Healthcare (AQH), Tirana str.
Prime Residence, C 4/3 Entrance D, Floor 6, Flat
No. 16, 10000 Pristina, Kosovo
arianabytyci@gmail.com
T. E. Dorner
Centre for Public Health, Department for Social and
Preventive Medicine, Medical University Vienna,
Kinderspitalgasse 15/I, 1090 Vienna, Austria
K. V. Stein
International Foundation for Integrated Care (IFIC), Wolfson
College, Linton Road, Oxford, UK
O. Maxhera
Main Family Medical Center (MFMC), Rr. Bedri
Pejani, 12000 Fushe Kosova, Kosovo
K Pilot study of an integrated care model using the geriatric assessment tool
ual care plan is drawn up jointly by a doctor, a nurse,
and a social worker and includes (1) problems of the
patient, (2) specific goals for each problem and (3)
activities to reach the goals.
Conclusion This intervention is one of the first in the
health system in Kosovo to implement integrated care
in a very vulnerable population. Physical training will
be an important tool to tackle many problems de-
tected through the geriatric assessment and which are
also associated with type 2 diabetes mellitus.
Keywords Integrated care · Geriatric assessment ·
Type 2 diabetes mellitus · Individual care plan · Older
people
Introduction
Type 2 diabetes mellitus more often effects people
with higher age and they often suffer from a large
list of comorbidities and medical as well as social ad-
verse conditions. These include cardiovascular dis-
eases, osteoarthritis, dementia, depression, and re-
current falls as common comorbidities, and problems
regarding continence, nutrition, mobility, and disabil-
ities in activities of daily living (ADL) and instrumen-
tal activities of daily living (IADL) [1]. Many of these
conditions do not fit into organ-based disease cate-
gories and are therefore often unrecognized and in-
adequately addressed in routine care; however, these
conditions have major impact on quality of life, dis-
ability, and health care utilization. In a standardized
geriatric assessment, these health conditions can be
revealed. The geriatric assessment is an examination
of older people with the aim to identify the medical,
psychological, and social resources and problems of
an older person, and to use it as a basis to develop
a comprehensive individual care and re-enablement
plan.
273
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Including all these aspects in the care for older
patients with type 2 diabetes mellitus makes the
endeavor complex and a comprehensive care plan
requires involvement of different health professions
as well as the social system. This care plan should be
developed along the continuum of care, from health
promotion, prevention, and curing to rehabilitation.
Consequently, and depending on the complexity of
the underlying problems, this demands a thorough
coordination of the different parts involved. Inte-
grated care has the aim to fulfill all of those demands,
and integrated care for type 2 diabetes mellitus has
been shown to improve glycemic control, improve
exercise capacity and physical function, as well as
quality of life, and is associated with higher patient
satisfaction, improved adherence to treatment guide-
lines, reduced hospital admissions and length of
hospital stay. In some studies, it was also found to
reduce the costs of health care services [2].
Physical activity and physical training (in terms of
endurance as well as strength) is an important tool in
the treatment of type 2 diabetes mellitus [3]. Espe-
cially in older persons, physical training contributes
not only to the reduction of insulin resistance, but
also towards health benefits like reduction of sarcope-
nia and frailty. It also reduces the risk of falls and ADL
deficits, can increase cognition and improve mental
health, as well as social participation, and ultimately
reduce isolation and dependency. Hence, physical
training reduces the risk of morbidity and mortality
and increases the overall health, well-being, and qual-
ity of life. Because of these many reasons, physical
training needs to be integrated into the care of older
people with type 2 diabetes mellitus.
Even though the population of Kosovo is on aver-
age the youngest in southeast Europe, it is following
the global ageing trend, where the population aged 65
years and over has increased from 4.6% in 1966 to 6.7%
in 2011. Based on a study which assessed the preva-
lence and the demographic and socioeconomic corre-
lates of chronic morbidity in the older population of
Kosovo in 2011, it was reported that the most preva-
lent chronic conditions were cardiovascular diseases
(63%) followed by diseases of the stomach and liver
(21%), type 2 diabetes mellitus (18%), and lung dis-
eases (16%). In this study population, the maximum
number of chronic conditions was six, whereas the
median number of diseases was two. The most con-
sistent correlates of chronic morbidity and/or multi-
morbidity in this study population were older age and
inability to access medical care [4].
Other studies on older adults in Kosovo reported
a relatively low degree of social participation. Older
people who are less socially engaged are possible tar-
get groups for public health interventions, therefore
targeted policies, specific programs and interventions
should be designed in Kosovo to engage older people
in the social activities [5]. A population-based survey
which assessed the regular physical activity of older
274 Pilot study of an integrated care model using the geriatric assessment tool
people in Kosovo showed a very low level of regu-
lar physical activities, especially among older women.
From the study population, around 14.3% of the older
people reported to practice regular physical activities,
with more males than females engaging in such activ-
ities (20.2% vs. 9.2%, respectively). The proportions
of those practicing regular exercise declined with age:
18.0% of those aged 65–74 years were engaged in reg-
ular exercise, against only 5.6% of those aged 85 years
or older [6].
In Kosovo, the socioeconomic support of the pop-
ulation aged 65 years and over is regulated through
legislative measures; however, current national pro-
grams, strategies and policies do not sufficiently ad-
dress the health needs and socioeconomic challenges
related to older people [7].
The Accessible Quality Healthcare (AQH) project in
Kosovo is funded by the Swiss Agency for Develop-
ment and Cooperation (SDC) and implemented by the
Swiss Tropical and Public Health Institute (Swiss TPH)
and Save the Children (NGO). It supports the imple-
mentation of a health reform, with a focus on primary
health care (PHC) and non-communicable diseases
in 12 municipalities of Kosovo. The AQH project is
piloting an integrated care model in one municipal-
ity, Fushe Kosova, that aims to improve the quality of
care provided for patients over the age of 65 years with
type 2 diabetes mellitus, through better coordination
of services provided by the health and social sectors.
Within this integrated care project, it was the aim
also to integrate a geriatric assessment tool and a spe-
cific individual care plan. The multiprofessional and
participative approach to establish this is described in
this paper, and the results are presented.
Methods
An explorative and emergent approach, using two
groups (1) a central working group (CWG) and (2)
a multisectoral implementation group (MIG) of health
and social professionals was chosen for this project.
The CWG consisted of representatives from the health
sector, social services, local non-governmental orga-
nizations, the patients’ rights association and the
association of retirees. The CWG was used as the
basis for looking at how the coordination of services
between health and social sectors, including com-
munity involvement, could be improved by adopt-
ing a patient-centered approach. The multisectoral
implementation group consisted of family doctors,
nurses, and social workers, from the municipality of
Fushe Kosova. The implementation group was used
to provide feedback on the different components
of the geriatric assessment and the individual care
plan as part of the integrated care intervention for
older patients with type 2 diabetes mellitus. Interna-
tional experts have supported the CWG and the MIG
throughout the process. While the experts brought
their experience and international best practice, it
K
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Individual Care Plan Form

Name and Last name of paent: Geriatric Care Plan team:
Date of birth: Family doctor
(Name and last name)
Tel of paent: Nurse
(Name and last name)
Date of Individual Care Plan: Social worker
(Name and last name)

Problem Goal Acvies*

Specific acvity Responsible person from the Target date for realizing the acvity
Geriatric Care Plan team
Suspicion of cognitive deficits Clarification of cognitive Neuro-psychologic tests Family doctor June 12
deficits
Imaging techniques Family doctor June 20

Maintain cognitive function Establish anti-dementive drug therapy Family doctor July 4

Establish physical training in group Nurse May 31

Problems in 4 assessed ADL- Decrease the number of ADLs Establish physical training in group Nurse May 31
Deficits which cannot be performed
independently
Prescribe mobility aid Family doctor / Social worker June 12

Make environment change together Social worker July 4

with patient´s daughter in law
*Rows can be added based on the volume of acvies
Date of the next planned Geriatric Care Plan:

¾ Aer the Care Plan is completed from the health and social professionals, set-up a meeng with a paent/paents’ relave to discuss the Care Plan

Did the paent agree with the Care Plan? (Yes/No) Date: Signature of paent:

Is Care Plan communicated with paents’ relaves? (Yes/No) Date: Signature of relave:

Relaon to paent:

Fig. 1 Individual care plan template

was the local working groups that ensured feasibility Results

and sustainability of the integrated care model at the
municipality level. Based on the discussions with the central working
Several workshops were held with both working group (CWG) and a multisectoral implementation
groups for the purpose of discussing the individual group (MIG) the geriatric assessment is composed of
needs of older people with type 2 diabetes mellitus the following single tools:
and designing and integrated care model. In the ini- 1. Functional status (ADL/IADL): questions from the
tial workshops, the concept of the geriatric assess- European Health Interview Survey (EHIS), wave 3;
ment was introduced and discussed, which resulted in [8]
identifying the measures and tools to be implemented 2. Urinary incontinence: 1 question from the As-
in the Fushe Kosova context. In the following work- sessing Care of Vulnerable Elders (ACOVE) project,
shops with both working groups, it was discussed how wave 2; [9]
to translate the findings from the geriatric assessment 3. Gait, balance, falls: 3 questions from the ACOVE
into an individual care plan. project, wave 2 [9]
As a result of the workshops, a template for an indi- 4. Depression: 2 questions from the Patient Health
vidual care plan was developed and agreed with both Questionnaire, wave 2 [10]
groups, along with the form for the geriatric assess- 5. Cognitive function: 3-word clock drawing test [11],
ment. Training and feedback sessions were held with 6. Frailty: Frailty Instrument from the Survey of Health,
the nurses, family doctors and social workers, who Ageing and Retirement in Europe (SHARE-FI) [12]
were tasked with performing the geriatric assessment
and defining the individual care plans. Throughout It was further agreed that a joint assessment is carried
the process, the older people’s and community per- out by two professionals, a nurse and social worker
spectives were actively involved in designing the inter- in the patients’ home. Based on the findings of the
vention through the patients’ rights association, a lo- geriatric assessment, a joint individualized care plan
cal NGO and the association of retirees. is developed by a multidisciplinary team comprising
a family doctor, a nurse and a social worker. The
provision of health and social services to patients

K Pilot study of an integrated care model using the geriatric assessment tool 275
 main topic
for management of type 2 diabetes mellitus is com-
prised of: patient education on diabetes management
and risk factors, self-management support, family/
caregiver support and management of clinical out-
comes. The individual care plan thus includes the
following three dimensions: (1) defined problems of
the patient, derived from the geriatric assessment, (2)
specific, measurable, achievable, relevant, and time
bound (SMART) goals for each of the patients’ prob-
lems and (3) activities to achieve the goals. For each
activity identified in the individual care plan, a person
responsible is assigned to ensure the task is carried
out on time. The prerequisite to involve the older
person (and their family) in drawing up the individual
care plan is formally recognized by necessitating their
signature on the plan. The multidisciplinary teams
all recognized this need during the feedback session
by including regular discussions with the patient and
their family as part of the implementation activities of
the plan. Furthermore, it should be made clear when
the next geriatric assessment will be performed. The
template for the individual care plan is shown in
Fig. 1.
Discussion
Integrated services and individual care planning are
new concepts in the Kosovo health care system. The
participatory approach of having a central multisec-
toral working group (CWG) which carries all decisions
regarding design and contextualisation and a multi-
sectoral implementation group (MIG) which is directly
responsible for implementing the interventions, en-
sures that all activities are locally driven and entirely
appropriate for the local context. This has been a huge
asset in ensuring a clear commitment to implemen-
tation of the integrated care model on the ground.
A monitoring and evaluation framework has been de-
veloped alongside the model and this is being used to
monitor the implementation of activities and evaluate
to what extent the quality of care for older people with
type 2 diabetes mellitus is improving.
The geriatric assessment form consists of a social
and a health assessment element. While developing
the assessment it was important to select tools, which
could be completed in a short time. The fact that
all sections of the geriatric assessment were chosen
from existing questionnaires or were validated tools
applied already in many population-based studies, is
relevant since the findings from the geriatric assess-
ment in Kosovo can be compared to findings from
populations in other countries.
The central working group (CWG) played a crucial
role in identifying the relevant sections of the geri-
atric assessment so that the problems identified in
the assessment could be addressed to deliver appro-
priate services. Furthermore, the mapping of avail-
able services in Fushe Kosova has been drafted, and it
is being used to tackle the problems identified in the
276 Pilot study of an integrated care model using the geriatric assessment tool
geriatric assessment. Geriatric screening and multi-
dimensional assessments are part of modernizing the
service delivery in many European countries. They
can be incorporated into practice without too much
difficulty, they meet with a high level of acceptance,
and they assist in involving different kinds of profes-
sions and to improve communication between them
[13].
The integrated care intervention in Kosovo has sim-
ilar principles and elements to a published study in
the USA, which tested the effectiveness of a geriatric
care management model on improving the quality of
care for low-income seniors in primary care. This
intervention also utilized a geriatric assessment tool
which was conducted by nurses and social workers
and an individual care plan was developed by a mul-
tidisciplinary team. The results of the published ran-
domized controlled trial showed that integrated and
home-based geriatric care management resulted in
improved quality of care and reduced acute care uti-
lization among a high-risk group. It was also reported
that patients enrolled in this intervention, compared
with usual care, received better quality of care and had
significant improvements in health-related quality of
life measures [14]. One of the strengths of the inte-
grated care intervention in Kosovo is that standardized
procedures have been established on how to perform
a geriatric assessment, how to derive a tailored indi-
vidual care plan on the basis of the findings of the
assessment, and how to deliver integrated services for
the treatment of type 2 diabetes mellitus. The next
step which is being implemented as part of this inter-
vention is the training program for nurses to increase
their competency level on delivering physical activ-
ity exercises to identified patients. Considering the
importance of physical activity and physical training
for physiological effects on type 2 diabetes mellitus
as well as most dimensions included in the geriatric
assessment, this training will enable nurses to pro-
vide advice and simple individual exercises for older
patients with type 2 diabetes mellitus based on their
identified needs and physical activity level. The focus
of training will be on individual home-based advice
and interventions, although reference will be made to
group activities.
As a conclusion, this integrated care intervention
is a new way of service delivery in the Kosovo health
system which targets a vulnerable population, aged
65 years and older with type 2 diabetes mellitus. This
intervention takes into account many health and so-
cial needs of this population, which are tackled by
a geriatric assessment and an individual care plan.
Acknowledgements We would like to thank the health and
social care staff from the Municipality of Fushe Kosova and
the multidisciplinary Working Group (WG) who are fully
committed to implement the integrated care project.
K

Conflict of interest Ariana Bytyci, Genc Ymerhalili, Thomas
Ernst Dorner, Katharina Viktoria Stein, and Osman Maxhera
declare that they have no conflict of interest.
References
1. Gadsby R, Barker P, Sinclair A. People living with diabetes
resident in nursing homes—assessing levels of disability
and nursing needs. Diabet Med. 2011;28(7):778–80.
https://doi.org/10.1111/j.1464-5491.2011.03261.x.
2. Martínez-González NA, Berchtold P, Ullman K, Busato A,
Egger M. Integrated care programmes for adults with
chronic conditions: a meta-review. Int J Qual Health
Care. 2014;26(5):561–70. https://doi.org/10.1093/intqhc/
mzu071.
3. American Diabetes Association (ADA). Standards of medi-
cal care in diabetes—2014. Diabetes Care. 2014;37(Suppl
1):14–80. https://doi.org/10.2337/dc14-S014.
4. Jerliu N, Toçi E, Burazeri G, Ramadani N, Brand H. Preva-
lence and socioeconomic correlates of chronic morbidity
among elderly people in Kosovo: a population-based sur-
vey. Bmc Geriatr. 2013;13:22. https://doi.org/10.1186/
1471-2318-13-22.
5. Jerliu N, Burazeri G, Toci E, Kempen GI, Jongen W, Ra-
madani N, Brand H. Social networks, social participation
and self-perceived health among older people in transi-
tional Kosovo. Eur J Public Health. 2014;24(2):333–7.
https://doi.org/10.1093/eurpub/ckt064.
6. Jerliu N, Krasniqi P, Berisha M, Ramadani N. Regular phys-
ical activity of older people in Kosovo: a population-based
survey. Eur J Public Health. 2015;25(suppl_3) https://doi.
org/10.1093/eurpub/ckv175.216.
7. Jerliu N, Toçi E, Burazeri G, Ramadani N, Brand H. Socioe-
conomic conditions of elderly people in Kosovo: a cross-
K Pilot study of an integrated care model using the geriatric assessment tool
main topic
sectional study. BMC Public Health. 2012;12:512. https://
doi.org/10.1186/1471-2458-12-512.
8. European Union. European Health Interview Survey (EHIS
wave 3). Methodological manual. 2018. https://ec.europa.
eu/eurostat/documents/3859598/8762193/KS-02-18-
240-EN-N.pdf/5fa53ed4-4367-41c4-b3f5-260ced9ff2f6..
9. Wenger NS, Roth CP, Shekelle PG, Young RT, Solomon DH,
Kamberg CJ, Chang JT, Louie R, Higashi T, MacLean CH,
Adams J, Min LC, Ransohoff K, Hoffing M, Reuben DB. A
practice-based intervention to improve primary care for
falls, urinary incontinence, and dementia. J Am Geriatr Soc.
2009;57:547–55.
10. Kroenke K, Spitzer RL, Williams JB. The patient health
questionnaire-2. Med Care. 2003;41:1284.
11. Siu AL. Screening for dementia and investigating its causes.
Ann Intern Med. 1991;115:122–32.
12. Romero-Ortuno R. The frailty instrument for primary care
of the survey of health, ageing and retirement in europe
predicts mortality similarly to a frailty index based on
comprehensive geriatric assessment. Geriatr Gerontol Int.
2013;13(2):497–504.
13. Leichsenring K. Developing integrated health and social
care services for older persons in Europe. Int J Integr Care.
2003;4:1568–4156.
14. Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB,
Stump TE, Ricketts GD. Geriatric care management for low-
income seniors: a randomized controlled trial. JAMA.
2007;298(22):2623–33.
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