New health practices say they take care of the health and well-being of each of us, but will they provide an opportunity to improve the lives of seniors at home in better conditions than today? How smart health help elderly ?What are these new health practices?How will medicine be revolutionized by technology?Are we all equal in becoming co-responsible for our health?

 

I. Introduction -The Silver Economy and innovation

The Silver Economy: Huge Potential

The Silver Economy concerns all the goods and services which can be designed in the various sectors of activity to cover the needs linked to the advancing age of the whole population.Today, it is a question of building the economy of active aging and of bringing out an industrial sector of excellence linked to advancing age.

The Silver Economy concerns the active elderly, the frail and the dependent in three areas: prevention, support and adaptation.

The policy pursued throughout the value chain is that of “Aging Well”, that is to say improving the quality and comfort of life of aging people. But also of the increase in their life expectancy and moreover without disability.

For the private sector, this involves concretely creating businesses, organizing new services, generating jobs, and increasing turnover in order to consolidate an industrial sector.

Today, the global Silver Economy market will exceed 130 billion in 2024, making the senior market a major player in the home food (60%), health (64%), household equipment (58%), leisure (57%) and insurance (56%).

Innovative technologies for healthcare

Technologies linked to long-distance medical monitoring, such as that of well-being, are already very real and rooted in the daily lives of patients. These transformations brought about by connected health (e-health) fit perfectly into an increasingly virtual world. These new health practices claim to take care of the health and well-being of each of us, but will they give the opportunity to extend the life of the elderly at home in better conditions than today?

The objectives of connected health are to enable the communication of personal health data to health professionals via applications running on a smartphone or tablet. This information can then be shared and exchanged within databases with the aim of advancing medical research, launching alerts (suspicion of an epidemic danger, for example) and thus putting under control “everything” which would hamper the patient’s health. At any time, the connected person will be able to know his condition and the evolution of his parameters in real time, just like the health professionals who accompany him. Therein lies the revolution announced by connected health on the move today. And that’s not all. The patient will be exempt from having to make an appointment for an examination or a consultation with his general practitioner or with a specialist, for example. He can already take these steps from home today in some cases. If his condition still requires a follow-up visit, online consultation is possible in the Internet in certain cases. A set of facilities to save travel when you are not well.

These new ways of conceiving medicine will revolutionize it. Ways of preventing and treating disease will also change. The possibility of comparing the data transmitted with thousands of others in order to refine a diagnosis, for example, will come naturally. Surgeons will operate together and remotely on the same patient. “The patient is no longer faced with a single person who manages his health in an emergency, but with a network of people who can give advice in real time.”

Technologies in general, coupled with communication and information techniques, offer possibilities that most of us do not even imagine. The vast field covered by health is in the crosshairs of many technological innovations: robotics (assistance robots), home automation (smart home with various and remote control systems), connected objects (health and wellness applications) , mobile health (loading of applications such as blood pressure measurement, for example), teleconsultation (Internet consultation), medical remote monitoring (remote interpretation of data necessary for the medical follow-up of a patient), tele-assistance (by videoconference for wound care, for example or remote alarm for the elderly, pregnant women, people with disabilities, etc.), prescription help (check the compatibility of treatment drugs), electronic pill box (or smart reminder medication), computerized medical record (centralization of patient data in a single record), personal coaching read (fitness application, or even dietary monitoring in cases of obesity), forums and discussion communities … to name a few, and the list of applications of the future is long. It already occupies the virtual landscape which is becoming more and more familiar to us and even often proves to be (too) intrusive. We are already inundated today with proposals for purchases and information, the veracity and effectiveness of which it is often impossible to verify due to the lack of legal references. These technologies develop faster than the legislations which must control them, certify them and protect the patient.

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II.Proliferation of technologies in the field of health and well-being in the broad sense

According to WHO forecasts, the number of people aged 85 and over will increase by 2 by 2050 . This increase will be accompanied by annoyances linked to advanced age such as dependence, the development of chronic diseases as well as the multiplication of multiple pathologies from which the oldest suffer. These groups of elderly people are the target of a section of the economy called the Silver economy, a real financial windfall that covers the services and products intended to meet the needs linked to aging populations in all sectors of activity: l adapted housing, for example, leisure activities designed for the elderly, marketing for the elderly, the aim of which is to promote the marketing of a targeted product or service, and of course, the gerontechnology sector, which takes a good share of the cake. Because the financial stakes are colossal. This context is unprecedented in human history.

In addition, the first choice of seniors to stay living at home for as long as possible increases the creativity of investors in the field of technologies that allow them to stay living at home. Technologies that focus on aging are exploding more particularly in areas that affect the weakening of old audiences. Are concerned, loss of autonomy, increased risk of falls, difficulty moving, the need for outside help, undernutrition, the development of chronic pathologies, various sufferings related to loneliness and feeling of isolation mainly through health and wellness applications (self-measurement and monitoring of blood pressure, heart rate, blood sugar, movement sensors …).

All these modifications show that the monitoring formerly reserved for the medical world is becoming more and more accessible to the general public, via the web. Should we rejoice in all these upheavals? Certainly, as long as they are not a pretext for the elimination of local jobs necessary for the overall well-being of the elderly as well as of all people when they are vulnerable. And if we suspect that technological advances will give birth to new professions, this reality is still very little addressed. Little is said about it, this means that we are not preparing for these perspectives of new functions which require training, supervision, legislative framework, and above all, a solid and complete reflection on the elements that promote the good health of older audiences as well. that maintaining it.

II.1 Elderly people at home, at the center of a more efficient health system?

As the vast majority of older people want to continue living at home for as long as possible, they claim it as their first choice. With technologies, it is already possible, for example, to respond to this wish. Indeed, monitoring patients with heart failure, thanks to an implant that continuously measures the rhythm of the heart, is possible. The results are transmitted to the hospital, which checks the data regularly. This monitoring makes it possible to warn the patient when he must adapt his treatment while keeping him quietly at home.  For patients suffering from pain, morphine pumps can be connected and release more painkillers at the request of hospital nurses without this necessarily requiring a request from the patient. Examples of remote monitoring for other pathologies exist and will become more and more widespread with the development of connected health.

The smart pill box, for example, reminds the person when to take their medication. Without the person’s reaction, a central takes over and inquires of the reason why he did not take his treatment.

Home automation transforms the home into a smart home such as, for example, activation by remote control of lights or when the person gets up to go to the bathroom overnight. The remote control systems can also be programmed like the heating thermostat, but can also be used to open and close the shutters, make an inventory of the contents of the fridge and start to draw up the next shopping list according to the habits of the owner.

With the help of robotics, robots will be able in the near future to help people get up, move around, and lie down. They will cook (some robots already do this in restaurants in Asia), serve meals, will be able to call a central if they detect anomalies in the behavior of the person they are accompanying … Robots are already receptionists in hospitals and hotels, etc.

The possibilities are endless. In particular, we can easily see the prospect of hospitalization at home and the upheavals it could produce to the patient and their relatives.

II.2 Questions remain

The aging of the population and the development of chronic diseases justify that medicine and care be viewed differently in the future. Savings must be made and care must be reflected in another way thanks to the contribution of today’s and especially tomorrow’s technologies. Technologies must, however, support the patient and those around him and not replace the entire environment of the beneficiary. Technologies provide answers to the reshaping of the landscape of services and care in the health system that is ours today. But this new way of monitoring and controlling health also raises a number of questions, some more worrying than others. Important issues are linked to these technologies which want us good. We are going to point more specifically to the home hospital.

Some challenges of the home hospital ...

The home hospital consists of moving the care usually provided in a hospital environment to the home in order to reassure the patient by treating him (for chemotherapy, palliative care, etc.) in his familiar environment. But, “Compressing length of stay and reducing the volume of admissions should lighten the healthcare bill. “

Medical technological advances are such that accommodation and care in hospitals are no longer a systematic necessity. With this change of course, should we not fear the growing decline in the length of hospital stays as announced? Will the stays simply disappear little by little? Won’t the hospital move to the heart of the house and make pathology the sole center of attention for all? Should we fear that hospitalization at home will one day try to equal hospitalization in a hospital environment? And how can we ensure proper follow-up of patients while responding to the inequalities of geographic disparities between hospitals which will have to coordinate the hospital-home link? Are all patients potentially candidates for home hospital? Who will decide who will benefit from this home infrastructure? Coordination and numerous collaborations between home and hospital care providers must be effective if this system is to be efficient for the patient. Today these synergies are practically non-existent. It is a real adaptation of the practices that we will have to constantly coordinate. And we know in the field of palliative care and end of life, how much a system like this could or could not guarantee the last moments of life with dignity and respect for the wishes expressed by the person.

Yesterday, the patient called the doctor at the onset of a symptom, then followed the directions of medical professionals for his recovery. Connected health offers new possibilities to improve, in particular, self-measurement gestures, as well as the desire for self-control and empowerment in relation to health. For diabetes, for example, the patient must anticipate complications and even act when they arise. The patient must learn to judge his own situation to decide whether or not to call the doctor. This requires good health education “and must be part of a participatory health culture”.

Training in the use of digital technology, by healthcare professionals and patients alike, is a major challenge for the future of connected health. Are we all capable of meeting our responsibilities? “. Do we all have the capacity and the will to take on this responsibility? Will we have sufficient and constant motivation to become a (co) responsible actor of our health: the close collaboration between patients, health professionals and the mastery of digital and communication technologies as well as information are- possible in all circumstances? Will the elderly and very elderly who are vulnerable have enough strength to integrate into this vast connected health system (the same question arises for vulnerable populations)? Will they not feel deprived of their personal health data and thereby their privacy when loved ones will have to connect for them via applications or medical programs that exceed them?

All these changes will still draw a lot of satisfaction and as many questions and disappointments with which we will have to learn to live. A real education in these new technologies will have to be part of the curricula of health actors, starting with the patient himself.

The development of access to information seems to us to require questioning media education. As we have emphasized, it is essential. Indeed, finding, understanding, decoding and using health information requires knowledge. The exclusion linked to the “digital divide” exists today, especially in rural areas, among the elderly and / or the vulnerable.

What services do elderly people who are frail or losing their autonomy need by the future?

For the majority of elderly people, having support allowing them to stay at home for as long as possible constitutes a fundamental expected service, whether it is independent or collective housing of the intermediate housing type. It implies guaranteeing the permanence and the same accessibility and continuity of care and services at home and in institutions, including for unscheduled care, while these people have reduced mobility and a need for more frequent recourse to the healthcare system. care. It also means guaranteeing the quality and safety of this care. Indeed, the phases of deterioration of autonomy sometimes find their origin in the care system: drug iatrogenism, hospital (especially following recourse to emergencies) … For these people, even more than for the rest of the population, it is appropriate to question the logic of hyperspecialization, which results in avoidable hospital episodes from which they too often emerge less independently.

To concretely decline these expected services, the elderly must be distinguished:

– Fragile:

They are people who have just retired. They are completely independent, capable of making decisions, of acting freely (without assistance) and mobile. They face everyday problems and are able to prepare for their future: nutritional advice, physical activity, maintaining a social bond, cognitive stimulation and possibly learning methods that can be used during the next phase. Health is weakening,the risk of falls is increased,the isolation is more and more frequent.

.for which the concepts of prevention, of early identification of situations likely to deteriorate under the concept of “high value care” which could be translated into care with high added value. These are indeed populations exposed to numerous risks of complications and hospitalization, which should be better identified in particular for those furthest from the health and social systems.

.who may have specific sanitary needs of the type operation in a health establishment, for which it is necessary to fight against iatrogenism and to organize well, in proximity, the upstream and downstream of the interventions

• Polypathological and loss of autonomy

These elderly person sometimes suffers from health problems due to age, but in a reversible manner. There is the problem of fall prevention, nutrition and the fight against isolation. Accommodation in a dedicated structure, more or less medical, is necessary, for the others, in better health the fact of staying as long as possible at home is an important point.

Difficult to move, a diminishing social life, cognitive disorders that appear, home asistant becomes a need

They need a multiprofessional proximity team that follows and guides them, in ambulatory if they are mobile, and otherwise in their place of life. In the heaviest cases, it is necessary to have a night nurse or a nursing professional on duty, while bearing in mind that such distinctions, useful as they are, differentiate between situations which in reality sometimes coincide. . In all complex cases, a professional or a structure playing the role of “autonomy coordinator” must be in charge of implementing open-plan services.

Among the health services expected nearby and in recourse also include:

– access to specialized care and procedures, in particular in ophthalmology, otolaryngology (ENT) and dental (the latter having an impact on nutrition by conditioning the quality of chewing), with the physical presence of doctor or dentist when necessary. Elderly people who are not able to use hearing aids and dentures correctly need help from other professionals, trained to check that the equipment is in working order and in use

– the immediate and timely management of unscheduled needs related to the appearance of health problems or decompensations of existing pathologies, in particular the consultation of specialists and series of examinations if necessary

To qualify the social and medico-social needs, it is possible to rely on the work in progress of functional modeling of innovative home support devices:

– help in carrying out the acts of daily life: management of the body and meals, maintenance of the accommodation, transport

– geriatric and emergency monitoring (home care, emergency accommodation, resetting, etc.)

– activities contributing to the maintenance and rehabilitation of functional and cognitive capacities (day care, poles of activities and adapted care, specialized Alzheimer team, prevention actions, etc.)

– practical support: assistance with administrative management acts (in particular for access to rights, care and assistance), the use of communication devices and techniques, concierge and organization of other services (hairdresser, etc.)

– support for carers, who play a key role in home support (through the support they provide themselves, their tracking and coordination function, etc.) and are very often women, in particular to avoid the risks of disinsertion professional

– adaptation of the accommodation: assessment of the necessary adaptations, assistance in the choice of service providers, support for administrative procedures and monitoring of work completion

– social participation: social and leisure activities, company time. This dimension is fundamental given the major role of the fight against isolation in maintaining autonomy. It includes elements related to care and technical aids, for example hearing aids

This support must be built with people and consistent with their life plans. This requires giving the elderly and their loved ones a role in the benefits provided to them, notably for the purpose of preserving their autonomy. They need accessible, readable and understandable information on health, services and social rights in general, as well as specific information on their support and all the offers adapted to their situation in the territory. where they live. Information tools must be designed for and with older people and harness the potential of current technologies.

The elderly must, if they wish, end their days at home, with dignity and with respect for their rights and freedoms, and have access to all the services they need for this, palliative care in particular.

The variability of expectations with regard to the services to be rendered must be taken into account, even if the question of choice raises difficult ethical questions for people whose cognitive functions are the most impaired. Remarkable advances in medicine during the twentieth century have led to giving it an important place in the management of problems linked to old age, but this medicalization is recent. Needs in this area remain variable depending on representations of old age and the life plans of the elderly. Some people will therefore prefer remedies (technical solutions, services) to interventions aimed at treating health problems, if these interventions have risks of failure and significant side effects. Likewise, if certain elderly people prefer a medical and secure environment, others value their autonomy, certain activities even risky, the fact of living at home. The social, family, friendly, neighborhood environment, etc. modify the terms of this arbitration.

Isolation is often a major factor preventing people from staying at home. If relatives provide favorable support for the free will of the elderly, they can privilege, more than the elderly would themselves, their security over their freedom5. The question of the level and nature of the efforts that carers can and want to make to allow their loved ones to stay in their home, the substitutability or complementarity between professional and non-professional carers, must also be legitimately taken into account. .

The level of solvency of expenses linked to old age, and the consistency of pricing, between the home and the range of establishments and homes for the elderly, public and private, also constitute important subjects for the economic model of the various structures. and their distribution on the territory, as well as for the freedom of choice of the users. The rest of the dependent must remain bearable for the elderly and their families and the conditions for funding the support must restrict their choice of residence as little as possible, even if this freedom of choice will always be limited.

In quantitative terms, if longevity gains will continue to translate into an increase in the number of elderly people, the increase in health needs linked to the increase in the share of  more than 65 year olds in the population constitutes a window of opportunity to strengthen the local network.

What response to these needs?

Responding to the needs of the elderly who are frail or losing their independence requires the establishment of a “package of organized services”, associated with technical solutions, defined with people and their entourage by mobilizing existing models of ” shared decision in health care ”. This response must be organized over time in a logic of “journey”. Equal access must be guaranteed, everywhere in the country and regardless of the resources of the persons concerned. The quality of the services provided, at home or in medico-social establishments, must be better assessed, taking into account the existing disparities. This would shed light on quality improvement policies, and the choices of users and regulators.

A significant increase in local resources must be made (notwithstanding the needs of referral and referral establishments) accompanying the structuring of care and services at home or on an outpatient basis and the upgrading of institutions. This increase must take place in the context of an expected temporary decrease in the density of doctors: corrected to take into account the greater needs of an older population, this density will reach around 2025 its level of the mid-1990s, before d ‘increase again. At the same time, the demography of other professions, in particular nurses and masseurs-physiotherapists, will be more dynamic, going in a direction favorable to the support of the frail elderly and those losing their autonomy. These dynamics are obviously contrasted according to the territories; in particular :

– certain sparse regions, particularly in central France, today have a high proportion of elderly people but will not age anymore; they are faced with problems of isolation of the elderly and of attractiveness for professionals

– on the other hand, other regions will experience an aging of their population, in particular certain large cities such as Paris, Nantes, Rennes, Montpellier, Orléans, and the peri-urban areas of the 1970s which have remained fairly young until now, as well as the southern and western coastal regions which already have a relatively old population. The challenge will be to adapt the capacities to support this increase, in regions perceived, depending on the case, as more or less attractive by professionals.

The structuring of the local offer – The chronic pathologies often suffered by very old people deprived of autonomy, necessitate the intervention of many specialized professionals. In order to assess the number of professionals whose intervention is required in the treatment and follow-up of the patient and to study the possible coordination methods recommended, the HCAAM analyzed six medical guides (and “lists of acts and services “) Of the French National Authority for Health relating to long-term disorders common in the elderly, related to or which may lead to a loss of autonomy. This study clearly highlights the large number of stakeholders involved in the treatment and monitoring of patients: out of the 6 of the long-term conditions studied, this number ranges from 12 to 30 different health professionals, and from 1 to 4 types. different social workers. This simple observation leads to an obvious need for coordination, in order to ensure effective patient management. This coordination is made difficult today by organization and funding in silos, a lack of leadership and capacity to invest, difficulties in getting actors to work together, and an information system that is still insufficiently interoperable.

The local territorial network must therefore organize itself to meet the health, medico-social or social needs of the elderly in a living area. It must integrate ambulatory care including specialists and health centers, pharmacies and local mental health services, home services (Home nursing services, Home support and assistance services, Services multipurpose help and home care and medico-social establishments, in particular accommodation establishments for dependent elderly people but also the whole offer of intermediate housing such as inclusive habitats. -sociales supposes in particular to harmonize the sanitary tools (personalized health plan) and medico-social tools (assistance plans) and to coordinate the two, to have tools to assess individual needs and help in practice which integrate the multidisciplinary dimension of care, the social environment of people, their expectations and those of those around them. On an outpatient basis, grouping must become the rule, in variable forms which do not all involve physical grouping. It will promote more successful forms of cooperation. Each professional will therefore have to contract at the territorial level within the framework of the local network. The professional communities will provide the interface with the establishments in charge of proximity and the establishments and services of hospitalization at home, as well as with the actors of second or third line, in particular the establishments of recourse or reference.

The establishments in charge of proximity will have an essential role in supporting the elderly. These are nearby health establishments and follow-up and rehabilitation establishments, refocused on multi-purpose medicine activities, in particular in geriatrics. They must have a flounce of beds allowing, on the one hand, to limit the irrelevant recourse to hospitalizations in establishments having heavy technical platforms, on the other hand, to organize discharges of hospitalization in the center of recourse, and finally to facilitate the permanence and continuity of care. They may include mobile teams, long-term care units and certain interventional activities. Home hospital establishments are stakeholders in these new organizations and are set to see their activities develop in place of hospitalization with accommodation in establishments (chemotherapy sessions, transfusion, etc.). These local establishments can serve as a support point for the regulation of unscheduled care and emergencies, with a platform of local imagery and routine biology, by mobilizing advanced nursing practices, under the responsibility from the doctor.

Coordination, essential for supporting the elderly, is first and foremost a full mission of the suppliers themselves. Therefore, the time spent on administrative tasks, which is expected to grow, must be outsourced and shared for a part, with the development of the professions of assistants in general practice, administrative assistants, engineers, data managers, service providers… to free up care time for the elderly.

Establishments and healthcare professionals at the resort levels, including the geronto-poles, will have to strongly articulate their interventions with those of local actors to take charge of an aging population, within the framework of renewed missions and taking into account the missions to entrust to the local network:

– specialized expertise, in particular geronto-psychiatric, likely to be mobilized on the initiative of local players, by request for an opinion or consultation, if necessary remotely

– development of multisite activities and mobile or projected teams on the territory, for patients subjected to iterative care which can be spread over long periods (sessions in particular) or for certain consultations

– very strong attention paid to the gerontological dimension which justifies the development of transversal organizations necessary for the quality of patient support in all of the departments of the establishments

– collaboration with the local network responsible for upstream and downstream hospitalizations

The distribution of tasks between the various players in the local network will vary according to the territory (degree of organization of ambulatory medical teams, medical demography, etc.), the social context and the characteristics of the housing of the elderly.

The local network will be able to take care of the medicalization of nursing homes which, due to their small size, are not able to organize it. Community health facilities can provide support to ensure access to care when necessary, with the help of new technologies and the possibilities offered by telemedicine.

III.The role of nursing homes and home care

The NURSING HOMES are a model of retirement home developed in the 1990s and deployed since then, heritage of “the humanization of hospices”, then of a medicalization policy built at a time when the burden of care was still modest. The growth in the number of nursing homes is also the result of a policy of creation of places and medicalization, which was reinforced after the heat wave of 2003. The quantitative objectives as for the number of places could be reached, exceeded even, with however a maintenance of territorial disparities. Ten years ago the pressing issue was that of waiting lists. This question has almost disappeared.

There is a very large disparity in the situations between nursing homes in the public, private and associative sectors. The location, size and degree of loss of autonomy of residents vary according to the type of nursing home even if there is significant overlap. While the voluntary sector and the lucrative private sector have concentrated strongly and entered into a group logic, the public sector remains very fragmented. The majority of public nursing homes come from the public hospital service, where they are either autonomous or managed directly by a hospital, in which case internal coordination and pooling of resources are already in place. The other public establishments are territorial NURSING HOMESs generally attached to the Communal Centers of Social Action. Regarding the staff employed in nursing homes, there has been a significant volume of jobs in recent years and the public authorities have in fact spent a lot of money on the creation of places and medical care. The quality has improved, the building also. However, user expectations seem to have grown faster than advances.

The project was originally medico-social, hence the emphasis on life and settlement projects. This order was struck by the deformation of the population housed: a later, shorter reception, a very high prevalence rate of neuro-degenerative diseases of the Alzheimer’s type or related with numerous and sometimes severe behavioral disorders and a increasing care load, which in part annihilated the so-called “medicalization” efforts, not allowing more dense support at a given level of loss of autonomy. In fact, the objective workload has increased significantly, and this is particularly highlighted by recent social movements in establishments.

Professionals recall the threats already identified: growth in workload and the risk that it will become literally unbearable, evolution of the medico-social sector towards a more sanitary model, scarcity of mutual aid and solidarity practices within teams, underlying trend towards the individualisation of care – more in line with the expectations of “new generations of dependent elderly people, but difficult to reconcile with the constraints of community organization – or even reinforcement of user requirements (in terms of presence, availability, hygiene practices, etc.). Finally, the growing medicalization of establishments, in response to higher levels of dependence of residents, constitutes a major concern on the part of professionals, in particular because it comes up against their professional identity as they like to define, giving priority to “care”, global support, human relationships over the technical nature of care. This is a battle that seems to be waging between the NURSING HOMES and the hospital, the medico-social and the sanitary. The feeling prevails as well as the current developments go against what caregivers appreciate about their profession and what allows them to continue to invest despite working conditions which they consider difficult.

The question of the optimal size of nursing homes is also linked to that of the articulation of the different dimensions of these establishments, medico-social, but also health and social. Normative, management, land and economic constraints may have led to the creation of large establishments, often located on the outskirts, sometimes less conducive to the emergence of communities of residents and professionals. The emergence of small units in large units is a possible way of reconciliation.

The importance of forms of temporary accommodation was also affirmed to counteract the irreversibility of “placement” and provide respite for families. The priority given to the home, in accordance with the preferences expressed by a large majority of people, implies making the development of medico-social and social home services suitably articulated with local health services the preferred choice from a medium-term perspective. Indeed, in nursing homes, the “place of life” is often perceived as a decor arranged to compensate for the unthinkable – sanitary, even hospital – of the model, while service residences and independent residences have regained and given credibility once again. calf the concept of domicile within a collective institution. In fact, the question of domicile is structuring for the transformation of the establishment model: housing functionalities, centrality of the person, respect for rights, expression of citizenship, etc. We will also have to take into account the expectations of residents of the future, probably different from those of current residents.

If the challenge of structuring and strengthening such a proximity line is successful, then the evolution already at work will be reinforced, leading the NURSING HOMES to focus increasingly on the least autonomous elderly people, for whom life at home has become impossible due to behavioral or cognitive disorders, or even health problems requiring intensive support and supervision. However, if the number of these people will continue to increase by the future due to the pursuit of longevity gains, the acceleration linked to the arrival of the baby boom generations at the ages at which these problems become more frequent does not will take place only in the future.

How to deal with the development of innovative home support systems? Should we leave the responsibility to the actors in charge of this support, should we promote solutions pooling in a territory resources in institutions and outside? These are questions that will need to be learned. The answer is probably variable depending on the territory. One difficulty, however, is that the nursing resource is relatively modest within nursing homes (often with problems of absenteeism, turnover, attractiveness).

III.1 Better define the role of the various stakeholders

To give substance to the primordial notion of teamwork, it is necessary to clarify the role of each, taking into account possible developments in digital tools and in particular the deployment of the shared medical record; it is essential for successful home support for the elderly. It is a matter of anticipating the necessary changes, to support them and prevent them from being destabilizing:

– the nurses: it is advisable to deepen the field of competences conferred by the proper role nurses and to reinforce their autonomy as regards the base trade, in parallel with the emergence of advanced nursing practices. This profession must see its missions evolve to play a central role in supporting patients and in coordinating those working with frail elderly people or those who are losing their autonomy, within the framework of the first recourse and collaboration with the attending physician. , who is responsible for the diagnosis and the development of the care program, the nurse being in charge of the development of the nursing care process, integrating the care program, subject to the opinion of the attending physician. The evolutions of the nurses’ missions should enable them to differentiate the interventions falling within their competence from those, such as certain hygienic care, which they could organize and coordinate with other interveners such as caregivers or caregivers. annoying, under conditions which remain to be defined

– the role of the attending physician must be refocused on medical expertise thanks to office assistant positions and support from the paramedical professions. This is so that this expertise can be developed, not only through its diagnostic, therapeutic and medical coordination responsibilities for those working with its patients, but now also through its contribution to the organization of the relationship between city and health facility, between primary and secondary care, for medico-social articulation, population health care … Doctors will have to devote more time to patients, to analysis and decision, and less to implementation of these decisions, which could be organized in particular by nurses as part of local clinical coordination. The conditions for the implementation of deep sedation by general practitioners should be the subject of precise and operational recommendations, if the priority given to home support is to be made effective.

– rehabilitation professionals: they play a decisive role in maintaining autonomy and the framework of their interventions must be considered from this perspective

– the other specialist doctors must, beyond their expertise and specialized care missions, contribute within their field of competence to the definition of the conditions for implementing the support standards (especially in the case of polypathologies) and of organizing relations between the city and the healthcare establishment as well as with other professionals. For a certain number of them, they have a role to play in facilitating the access of elderly patients to the technical platforms and to the most specialized expertise in their field.

–  the role of pharmacists must integrate an advisory role associated with dispensing, facilitated by the fact that the elderly almost always go to the same pharmacist. They have, in particular, a role to play in the medication reconciliation and the fight against iatrogenism within the framework of cooperation between pharmacies, city professionals, health and medico-social establishments. In fact, polypathological patients, and in particular the elderly, are most often polymedicated. In addition, these prescriptions often have various prescribers: attending physician, specialists, health establishments or other professionals without reimbursement or self-medication. Unfortunately, although the training of pharmacists is entirely consistent in analyzing the risks of associations, their level of medical knowledge and in particular of the patient’s medical record and the various indications is insufficiently documented to be fully relevant. Regular confrontation between the different prescribers is essential. Thus, the pharmacist could organize, for his elderly patients, a review of their medications, asking all the parties involved to validate, in a dematerialized and asynchronous manner to facilitate organization, a consolidated prescription. This review could take place annually, as well as at the end of episodes of care (discharge from hospitalization for a common event with a prescription from the prescriber, surgeon or anesthesiologist, for example, not taking into account or resuming treatment for background). This act should be integrated into a flat rate as part of an extension / adaptation of the future in telemedicine, either by the creation of a new act, or by a similar type of teleconsultation concerning each of the actors who participated

– nursing assistants today have an essential role in nursing homes, where they are often alone at night. Their place is however limited in the ambulatory field. It is expected to develop, within frameworks to be defined (liberal status, hiring by nursing offices), as well as the recognition which this profession enjoys

– the intervention of professionals in the social sector (social workers accompanying the elderly in the mobilization of social aid, tax and social deductions, service benefits, etc., household helpers, carers, educational assistants and social, medico-sports educators or animators) is an integral part of the support protocol, in particular by helping to make it possible to stay at home. In particular, carers and household helpers provide a monitoring and tracking function, in conjunction with carers and nursing staff: by regularly communicating with the nurse or doctor they can alert them in time of what they observe on a daily basis, the latter then intervening better.

The training of different professionals must better integrate versatility and the gerontological dimension, as well as multidisciplinary work, in particular by providing joint training and integrating more teaching in the social sciences. Given the time required to train health professionals, these reforms must be implemented without delay.

The roles must be articulated, at the local level, within the framework of multiprofessional protocols of primary care established by the proximity teams. It must specify how the professionals, and in particular the doctor, the nurse and the pharmacist, organize themselves to collect data relating to patients, analyze them and determine whether and how to intervene. It must be carried out by the team itself on the basis of scientific data and recommendations taking into account the considerations inherent in the team, the population characteristics of the patient population, the resources, the characteristics of the territory and especially to the problems identified by the team in their exercise or by the patients. They can, for example, define the behavior to be followed by a biologist who detects a problem in a blood test, while his contacts are not equipped with secure messaging. Or what a caregiver should do when he sees an elderly person fall. This contractualization also concerns the links between ambulatory medicine and nursing homes.

As indicated above, this work of defining roles and coordination missions (medical on the one hand, caregiver and social, proximity, on the other).

III.2 Go to less moved patients

Less moved, people aged 70 or over move less often to the office of professionals, and a significant part of their use of care is done through visits by professionals to their homes. This particularly concerns private nurses, whose practice is almost exclusively focused on visits, regardless of the age of the patient. In addition, when people aged 70 or over reside in institutions, it is often professionals who travel if they are not already on site (as in most nursing homes). The question now arises of the organization of home visits for nursing staff, including doctors in a context where the number of their visits has decreased significantly in recent years, and the capacity to deliver within this framework. various treatments, including complex ones.

Here digital is an important element of response to bring to the elderly. Integration of all the actors of the local network as referral or referral structures in the same interoperability framework is a minimum requirement. The equipment necessary for the implementation of telehealth services (remote monitoring of biological constants, telesurveillance, teleconsultation) must be set up in structures of professional communities but also, for people with reduced mobility living at home or in institutions accommodation, in their place of life, which means equipping their home with a simple high speed communication medium (4G box type for example) and the communication interface (tablets… and soon “internet” televisions) ).

Regarding teleconsultations, in the context of chronic monitoring or of intercurrent elements that do not require a thorough clinical examination (for example, change in treatment or adaptation of drug doses -, taking cognizance of the results of additional exploration), the attending physician can initiate a teleconsultation appointment himself either directly with the patient, or with a family caregiver, or with a paramedic or even a life support provided that both have been trained. Within the framework of a request for a specialist recourse opinion, the attending physician can either initiate teleconsultation outside his presence with the specialist concerned, or schedule a consultation joint to his office in the presence of the patient and at a distance from the specialist in order to to be able to complete the necessary clinical or paraclinical examination (electrocardiogram (ECG), spirometry, etc.) – situation planned and financed in the endorsement. With regard to dental care, experiments in teleconsultations in nursing homes relating to pre-diagnosis and post-treatment follow-up are underway. For unscheduled consultations (for example dermatological “small emergencies”), the attending physician, or even the specialist in remedies, can after a brief interrogation decide whether a teleconsultation is sufficient. A physical examination and evaluation within the time limits established by the attending physician as part of a management protocol are essential. The elderly person’s ability to move around in a city office, while a prior face-to-face visit less than a year old is necessary to be able to initiate a teleconsultation session, must however be assessed. This visit must be adapted to the context and most often accompanied by a caregiver or paramedic. Note that the stages program concerns a very reduced pathological field since it only concerns five pathologies and is based exclusively on the remote monitoring of biological or parametric parameters (weight, blood sugar, HBa1C, creatinine, spirometry, ECG) and not on criteria particularly important clinical surveillance on this type of population. It therefore appears essential to extend the fixed-price telemonitoring programs to other fields (polypathologies, home support, oncology, etc.) than those of the stages program.

Denmark provides examples of the mobilization of such tools to support elderly people at home and avoid trips to the hospital, and in particular allow monitoring of their state of health (measures taken according to a personalized calendar) and their movements (detector movements, fall, location system …).

It is also possible that new technologies such as autonomous cars will give more mobility in the future to elderly people who are frail or have lost their autonomy, without it being possible to anticipate the consequences in terms of services here. to make and organize this response.

IV.Smart health Solutions

IV.1 Helping the elderly stay at home

Thanks to the development of innovative technologies and to professional services for autonomy, the uses of which are spreading, we are seeing the emergence of powerful levers of efficiency which, to play at full capacity, require “massive” investments and effective coordination.

The habits are taken and the daily rhythm of a life that slows down. Aging remains under control from the moment it is at home. The great fear of frail elderly people is that they will have to leave their reassuring environment for hospitalization or a nursing home.

In terms of an aging population, it is not relevant to target people solely on the basis of their age but rather in relation to key moments in life, for example the retirement which characterizes the elderly population. Two targets are more precisely identified in the Silver Economy:

• independent seniors,
• elderly people losing their autonomy.

 

 

.For the autonomous elderly

Solutions to help overcome these findings are constantly evolving. Home automation, communication tools and the development of medical technologies are the main ones. It is again a question of anticipating situations and accompanying the elderly in a daily life that becomes difficult. It is by listening to them that progress begins.

Several research projects in this area focus on the identification and assessment of the risks associated with walking around in everyday life. One of them aims to characterize the overall cognitive level of elderly people who have fallen

Build scalable housing

Preventive home improvements are possible and more than ever a necessity. So some real estate builders are developing habitats able to follow the evolution of residents and anticipate the difficulties of use that may arise over time. These scalable homes incorporate, from their design, equipment and pre-equipment intended to facilitate daily use, in particular for people with reduced mobility. Room by room, ergonomics, comfort and safety have been thought out down to the smallest detail, while optimizing scalability. Pre-wiring of doors to allow motorization, reinforcement of partitions for the installation of safety equipment, walk-in shower with non-slip floor, light path between bed and toilet, large sliding doors …

Inform about the advantages of new technologies

Many technologies dedicated to the elderly can support them or overcome their everyday problems. The natural reluctance to change, which exists for all of us, is exacerbated as we get older, preventing us from taking an interest in what technology can bring. Information and then, secondly, training, play a key role in its adoption here.

Secure medication intake

The aging of the population leads to the development of chronic pathologies and, sometimes, the patient’s taking of several drugs. The proliferation of generic drugs deprives patients of the visual cues of their treatments. Medication support solutions such as electronic pill organizers can help with treatment adherence.

Anticipate falls

The main risk for walking is falling, which is particularly common in the elderly. As attention processes deteriorate with age, postural stability may be impaired in situations of high stress. Most of the ambulation projects will therefore focus on this population for which the risk of falling could be increased due to an overall reduction in functional capacity, taking medication or fluctuations linked to the time of delivery. day. The consequences could be aggravated due to cognitive impairment and / or bone fragility.

In addition, and after numerous unsuccessful or unhappy attempts on the commercial front, more and more functional fall sensors have emerged in recent years.

These devices are all designed to automatically send alerts, by telephone or Internet, to a monitoring station or simply a person on his mobile phone responsible for carrying out an emergency rescue procedure. Some also incorporate the actimetry function.

.For loss of autonomy

Proposals to improve the daily lives of these elderly people who are losing their independence are quite naturally focused on housing and technology. Once again, they put the human being at the heart of concerns and dignity is the key word.

Adapt the accommodation

The daily operation of a home involves the manipulation of a set of mechanical and electrical devices: opening and closing of doors, windows, shutters, heating and air conditioning adjustment, lighting on and off, switching on. electronic devices (television, DVD player, stereo), household appliances or personal assistance. These are all gestures that can represent a difficulty for a person with a disability or reduced mobility. Home automation makes it possible to automate or control remotely all that can be it to allow a dependent person to control his environment in an autonomous way. Its harmonious integration into the home increases safety and well-being. There are different technologies for implementing these systems depending on the number of equipment to be ordered, the size of the premises, the skills and needs of the user.

Secure the place of life

Today, new technologies allow, through the improvement of networks, the installation of more and more efficient and discreet home automation sensors. Thus, thanks to a set of sensors, we can be informed in real time of a door that remains open, a light that remains on, or even of the frequency with which the refrigerator is opened, of a water leak, of a increase or decrease in temperature,… These are all signs likely to automatically trigger an alarm with a specialized platform or a family member.

Slowing down the onset of cognitive disorders, Numerous works in computer-assisted cognitive stimulation revolve around the neurological concepts that define the brain’s ability to modify both in its structures and in its functioning, throughout life, in the event of injuries or under the effect of appropriate stimulation.

Several systems have emerged in the field of stimulation of memory functions for the purpose of re-education or slowing down the degradation process. Cognitive stimulation software studies are taking place as part of improving the management of Alzheimer’s disease through cognitive stimulation. The objective is to test and evaluate in situ a set of technologies useful for patients with cognitive disorders, their family carers and all medical and social professionals.

Secure movement

Movement outside sometimes leads to fear on the part of the family because of the disorientation preventing them from returning home. Many devices are emerging ranging from the smartphone application to the GPS bracelet indicating the position of the person. This is an important area of ​​research.

Manage help and follow-up at home

Home help generates care by multiple workers. The liaison booklet so far in paper format can, thanks to digital tablets or pens, be filled in and kept at home while being searchable remotely in order to better prepare and anticipate these interventions.

Family caregivers

Some websites are developing aimed at bringing together caregivers / families by providing them with services such as:

-Stock exchange for equipment, loaned, given or sold, to reduce the cost of home care.

-Caregivers directory

-Directory of volunteers for a helping hand or for company, creation of social ties and intergenerational ties in the regions.

-Access for vulnerable people.

IV.2 Contribute to well-being and performance monitoring

Well-being and better living have become societal concerns. There are countless councils, apps and other connected devices that flourish every day and contribute to the search for … eternal youth.

A growing place of well-being

Stress, as well as the chronic lack of time associated with “modern life” leads to better self-care. Well-being is sought after by a gentle sporting activity which maintains form and reduces the effects of age. Intellectual well-being, curiosity, physical demands, meanwhile, are ways of pushing back the limits of old age a little more …

Better health

The constant increase in chronic diseases, the leading cause of death in the world, could be better managed by limiting risk factors such as obesity, inactivity, diabetes and even hypertension. Technology provides, through smartphones, tablets and connected objects, the means to become a real player in one’s health.

Development of applications

The quantified self phenomenon was born in San Francisco in 2006-2007 at the instigation of members of Wired Magazine. It is based on a host of tech accessories, connected to each other and connected to his computer and now especially to his Smartphone. The global Quantified Self market is represented $ 4 billion in 2014.

This movement was born from the growing desire to lead a healthier and more active life: take care of yourself, regulate your weight and maintain your shape, while being able to measure your efforts and therefore assess the benefits, direct.

Share your information on social networks

The desire to be well, to be fit and to live well is a fairly universal desire. With the added bonus of being able to share your results and encourage each other to promote self-determination.

A set of products and applications aims to measure, control and communicate the amount of activity performed, diet, hydration, fitness, well-being, calories burned, posture through sound Smartphone in order to draw advice and follow-up, and share the results on social networks.

Request from the sports world

It was the Italian cycling champion Moser who first used (1984) his heart rate to beat the hour record on the track using a rhythm thermostat. The world of top athletes is turning more and more to connected objects and sensors. The data thus collected makes it possible to assess endurance qualities, in order to set up a training protocol perfectly adapted to the benefit of better performance.

Suggestions

Virtual coaching

Video telephony is increasingly used for personalized coaching tele-sessions such as gymnastics or Tai Chi Chuan, the benefits of which for preventing falls are beginning to be recognized.

Through tablets and their many applications, we can now follow brain or physical training programs.

Develop robotics

The field covered by robotics ranges from the simplest to the most sophisticated. Thus, we will retain several families of robots:

– The very classic household robots seek to automate tedious tasks such as cleaning floors or assisting with cooking tasks. In terms of remote assistance, we are seeing automatic mechanisms capable of triggering alarms.

– Humanoid robots are and will be able to carry out household or care tasks. The idea of ​​creating robots capable of serving humans and performing in their place all kinds of strenuous, repetitive or dangerous tasks occupies a major place in the aims of current technoscience. Their use in the elderly is therefore not surprising and has been envisaged for several years by roboticists. Almost always humanoid in shape, these robots are presented as a companion solution with a “human relationship” perspective or as a complement or substitute for nursing staff.

– The companion robots, on the other hand, can take much less complex forms such as that of a character moving on the screen of a connected smartphone, tablet or television. Communicating in natural language, they then become an interface between man and machine in applications as diverse as the execution of daily tasks (telephone calls, device control, etc.), games, coaching or even medical applications.

Maintain social ties

The use of video telephony as an antidote to social isolation is beginning to grow. For example, a very useful use of videophony for social ties has been developed in Canada.

Family and intergenerational networks or proximity networks are increasingly the subject of experiments. The use of touch screens to avoid the use of the keyboard has become widespread across tablets and smartphones. These innovative solutions coupled with the establishment of specialized social networks allow elderly people who are not aware of technology to keep in touch with their children, grandchildren and friends.

Rethinking health platforms on the Internet

Almost half of the European population considers the Internet as an important source of information Medical. Thus, we no longer count the “health” sites which offer medical content too often not validated by professionals. Faced with the rise of the web around health issues, it is therefore essential to make this information reliable and to adapt its content to the knowledge of Internet users who have come to consult it.

IV.3 Innovating in Telemedicine

Telemedicine can be used in several fields:

-Permanence of imaging care.

– Management of stroke (Cerebrovascular Accidents)

-Health of detained persons,

– Management of a chronic disease

-Care in medico-social structure

The healthcare offer, particularly in the area of ​​”Aging and Disability”: teleconsultations in the required fields (geriatrics, dermatology, psychology, cardiology, etc.). Home telemonitoring solutions could also be implemented for the prevention and detection of falls, weight monitoring, nutrition, etc. for the elderly or weakened.

Suggestions

Improve medical follow-up

The medium or long-term monitoring of a person’s biological and environmental parameters at their place of life is a subject of research and development.

This is how weight, pulse, EKG, oximetry and many other biological parameters are captured directly on the person or through dedicated objects, analyzed by computers on site or remotely , merged into multivariate analysis models taking into account the entire medical file, and presented on screens for the purposes of therapeutic monitoring or epidemiological study.

Create new sensors

Advances in microtechnology allow, every day a little more, the design of new sensors aimed at:

-Decrease their consumption

– Increase their computing power, their robustness and their reliability

-Improve their lifespan

-Reduce their manufacturing cost

-In addition, other tracks are emerging with notably smart clothing or even invasive exosensors and sensors

Securing medical data

changes in connected health and data from sensors not validated by learned societies transiting through insecure smartphones.

It is necessary to imagine the means making it possible to secure these data from their creation to their hosting without forgetting their accessibility.

Managing disability

Disability must be managed in an evolutionary manner at the material, organizational and medical level. It is necessary to adapt housing, to put in place actions that supervise and assist, anticipate, verify, control and help the fragile.

IV.4 Build the hospital and the nursing home of tomorrow

It will make it possible to imagine the innovative solutions to be implemented in order to correspond to the new needs of patients and caregivers in correlation with the progress made by medicine.

Suggestions

Connect small hospitals and nursing homes, Telediagnosis, Teleconsult

Several projects consist in having healthcare professionals experiment with an audiovisual teleconsultation device between nursing homes(residential accommodation for dependent elderly people) on the one hand, and general practitioners and / or specialists on the other.

A camera connected to the nursing homes network allows nursing staff to show video, via a secure network, of patients to these doctors and, via a set of biomedical sensors (thermometer, blood pressure monitor, oximeter, glucometer, etc.) to send in real time the constants of these patients to allow the establishment of a diagnosis.

The main objective is to avoid a passage to hospital emergencies for vulnerable people and to facilitate their access to specialists in a context of quality of care by avoiding time-consuming and costly movement. The videoconference of gerontological teleconsultation and support for cognitive deficits is developing around the world today.

Designing digital hospital management

The digital hospital program launched revolves around 5 functional areas priority:

-Imaging and biology results

-The computerized and interoperable patient record

-The electronic prescription feeding the care plan

-The programming of resources and the patient’s agenda

– Medico-economic management

Up to now, the progress made has consisted more in the improvement of Hospital Information Systems which manage the administrative aspects of the patient than on medical data. But the future should not be limited to the ascent or the provision of the latter. As in other advanced sectors, more space should be left to more vertical tools that meet the very specific needs of certain specialties and / or pathologies in coordination and partnership with healthcare teams.

Imagine the hospital room of the future

In addition to its interior architecture offering a more optimized space, a better reception of visitors, an optimization of the functionalities of the beds (seated position) or even the use of materials promoting optimal hygiene, the hospital room of the future will give pride of place new information and communication technologies through, in particular, the use of a digital terminal which will inform the patient about his program for the day, his menus, will offer interactive content or practical information. It can be controlled by voice and allow access to the outside (telephony, Internet, television). This same terminal will also offer hospital staff full access to the patient’s medical file during in-room care.

Develop teaching by simulation of hospital staff

The initial and continuing training of medical and paramedical personnel is evolving towards solutions using new technologies. Like the flight simulators for pilots, the companion robots will allow a situation closer to reality, the parameters of which can be modified at leisure so as to simulate a situation encountered in the daily life of nursing staff. Similar to “serious games”, these simulators will also offer the advantage of not disturbing the operation of the services while improving patient safety.

V. Case :Support strategy for the elderly  In Denmark

In Denmark, an integrated support strategy for the elderly in the home, based on technological tools

As early as the 1970s, Denmark made home support a priority for the elderly. Since 1987, retirement homes have been considered as ordinary housing: the rights and duties of people in institutions are very close to those of the rest of the population. No retirement homes have been created since that date, and places in these facilities have declined (from around 27,600 in 2001 to 9,400 in 2009). Intermediate forms of accommodation, adapted to the needs of people experiencing loss of autonomy were then developed (for example, assisted living facilities, connected to a range of care services, remote monitoring, meal delivery, etc.) . This has been accompanied by a very large increase in the number of home nurses and people employed by municipalities providing home care.

In Denmark, the municipality is responsible for organizing support for the elderly, whether at home or in an institution. One of the peculiarities of the Danish strategy is to offer integrated support for these fragile populations: the municipality therefore has a duty to offer adaptations of the person’s home or, failing that, accommodation suited to their needs, as well as an offer support and care services. In particular, it is the municipal services which must propose a solution on leaving the hospital. Strong incentives have been taken in this direction: if the patient has to extend his stay in hospital for lack of a suitable solution for his discharge or because there is a waiting period, it is the municipality which bears the costs related to additional hospital days. As social services are the responsibility of the municipality and health services are financed and organized by the regional level, a case management system has been introduced to promote better coordination, on several levels.

At a first level, a “care manager” of the municipal services is responsible for assessing the needs of the person and proposing a set of aids likely to allow home support. For people aged 75 or over, this assessment is carried out in particular during the so-called annual prevention visit that the municipality has the obligation to organize at their home. Beyond the great diversity of practices depending on the municipality, we observe that the assessments are generally multidimensional: they cover both the aspects relating to the well-being of the person (functional capacities, lifestyle, housing conditions, possibility of ‘expression of a free choice …), as aspects relating to the state of health (current drug treatments, rehabilitation aids, …). Note that in Denmark there is no predefined level of loss of autonomy: the needs of the individual are assessed on a case-by-case basis and assistance aids are offered accordingly and can be readjusted as and when required. .

This role of needs assessment is most often performed by nurses in the sector, but also sometimes by occupational therapists, physiotherapists or even social workers. To fulfill this role, these professionals must already have worked for several years in the home services sector and have followed specific training (generally two weeks). The general practitioner of the elderly generally transmits information to the care manager of the municipality: he will ensure that the file is complete and will inform the patient (and his family) on the various aspects of support. .

Once the evaluation has been carried out, the municipality offers suitable accommodation (or accommodation) and a wide range of services (remote sensing system, remote monitoring, help with cleaning, portage of meals, personal assistance, assistance transport, adapted physical exercises, etc.). Added to this are the health services offered essentially by home care teams (nurses), continuously (24 hours a day): care and treatment, patient education, assistance in filling out administrative request files for various needs. (for example, change of apartment, emergency aid, access to a center for the elderly, etc.). In addition, geriatric teams or geriatricians working in the hospital provide supportive medical consultations, in particular for the elderly who present very complex situations or for whom institutionalization would be indicated.

Health professionals (nurses, possibly general practitioners, geriatricians) and providers of concrete help (home helpers, housekeepers or even volunteers) work together to coordinate. At this second level of coordination, it is the home care team – the nurses – that plays a key role on a daily basis.

However, even if the Danish system offers relatively well integrated support, it should be noted that problems of coordination may appear, in particular between hospital care services administered at regional level and social services which are the responsibility of the municipalities.

VI. Conclusion

In the case of the frail elderly or those losing their autonomy, the problem of health and medico-social integration, and the services delivered at home, is a major one.

It is the 65-85 age group whose share in the population will increase sharply. At these ages health problems and frailty become more frequent, but the majority of people remain independent. The expected increase in needs over this horizon therefore relates above all to prevention, screening, monitoring of chronic pathologies and specific health needs, which must be met by paying attention to iatrogenic, upstream and downstream of interventions. This period constitutes a window of opportunity to strengthen the local network. If the progression of needs in the future is above all health, it is also necessary to develop and better coordinate the medico-social support which benefits people with loss of autonomy at home.

The prospective work carried out here aims to shed light on the characteristics of the offer with innovative technologies meeting the health needs of elderly people who are frail or who will lose their independence in the future. This is why a certain number of major questions are not addressed there: the level of solvency of the expenses related to the old age, the coherence of the tariffs, between the domicile and the palette of establishments and habitats for the elderly, public and private. ; moreover, the redefinition of the trades and the clarification of the roles of the various health professionals are only sketched there. These questions will be the subject of further work.

 

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