Pilot study of an integrated care model using the geriatric assessment tool

Older people with type 2 diabetes mellitus often suffer from adverse medical and social conditions 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 disease. The Accessible Quality Healthcare project in Kosovo, is piloting an integrated care model for patients 65 years and over with type 2 diabetes mellitus, which also introduces comprehensive geriatric assessment and care planning.

In this study two groups (1) a central working group and (2) a multisectoral implementation group of health and social care professionals were established to develop a geriatric assessment form and an individual care plan form for this project.

The groups decided to address the following problems in the geriatric assessment: activities of daily living, urinary incontinence, gait, balance, falls, depression, cognitive function, and frailty. The assessment is carried out by a nurse and a social worker in the living environment of the patient, and the individual 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.

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 detected through the geriatric assessment and which are also associated with type 2 diabetes mellitus.