Rev. Bras. Geriatr. Gerontol.

2023;26:e230233

Chronic diseases and longevity: future challenges

Original Articles
1 of 20

Renato Peixoto Veras1 ID

Abstract
This text proposes the design of care models that are more effective and appropriate
for the characteristics of the aged population. To this end, the article expounds on the
need for emphasis on low-complexity care that focuses on coordination, prevention Keywords: Older adults.
and client monitoring to reduce wastefulness, offer better quality care and lower costs. Care Models. Instruments.
Furthermore, the epidemiological assessment instruments used and the detailed routine of Epidemiological Evaluation.
all health professionals are presented. Thus, it is endeavoured to deliver the best care for Health Professionals.
the aged and, within an estimated timeframe of around 20 years, render this sustainable,
transforming not only care for this segment of users, but for the health system as a whole.

1
Universidade do Estado do Rio de Janeiro, Universidade Aberta da Terceira Idade. Rio de Janeiro, RJ,
Brasil.

No funding was received in relation to the present study.

The author declare that there is no conflict in the conception of this work.

Correspondence
Renato Peixoto Veras Received: October 08, 2023
unativeras@gmail.com Approved: October 27, 2023

http://dx.doi.org/10.1590/1981-22562023026.230233.en
Contemporary care model for the elderly: the current need

INTRODUCTION to cut down on wastefulness, toward providing

high quality, low-cost care. The instruments used
Can healthy aging with quality of life be achieved for epidemiological assessment are also described,
in Brazil? The aim of the present article is to address along with a detailed breakdown of the healthcare
this question via a resolutive care model offering team routine.
excellent cost-benefit ratio, congruent with the latest
solutions in integrated care for the aged population. Incorporating the knowledge, theory and
application of these instruments into daily clinical 2 of 20
The model presented seeks to rethink in a routine is pivotal for this care logic to expand and offer
completely innovative fashion, the care which should improved care to the older population, representing
be provided to this contingent of the population, the fastest growing age group worldwide. Failure to
the importance of health care, promotion and change the care model for older adults could spell
prevention, along with the technology for use in dire consequences for the future.
consultations, monitoring and information, i.e., in
the “coordination of novel care approaches”. Therefore, the primary objective of this article
is to design more effective care models tailored to
The increase in life expectancy of the Brazilian the specific characteristics of the aged population.
population represents a major advancement. Live Re-examining healthcare treatment is critical, where
longer – grow old – this has become a reality in this one thing is certain, the care delivered in the future
decade and is set to become even more so in the years will have to be far more effective than currently1.
to come. However, citizens having the opportunity
to live these extra years to the full while maintaining All of the demographic predictions about growth
functional capacity, health and quality of life, is also of the older population made in the 1980s have
an important part of this advance. In recent years, materialized. If anything, these estimates have erred
a number of institutions and their research teams toward underestimating the trends, since figures are
have investigated changes in the model of health even greater than initially envisaged1-3. Increased
service provision. Clearly, there is an imminent need longevity is a major triumph for mankind.
for such a shift.
Surviving into late-life used to be a rare privilege
The health care of the older population can be that, today, has become something of a norm in Brazil
restructured in the sector toward providing better and likewise among many developing countries.
care outcomes at a lower cost. For this shift to come
about, all actors in the sector must take a lead in Drawing on the definition of active aging, 3 key
achieving the necessary changes and be open to pillars of this paradigm emerge: health, participation
innovation. In many instances, innovating may and security4,5. The health pillar transcends the purely
merely require returning to simpler care practices physical realm – a fact backed by evidence from a
and recovering values lost amid the current national host of scientific fields – to encompass the area of
health system. mental health and social wellbeing, all recommended
targets of public policy interventions.
In today´s reality, living into one´s 80s, 90s
or beyond has become relatively commonplace.
Nevertheless, there are deep concerns over the DEVELOPMENT
current care model, since these additional years of
life should not be marked by suffering, pain and In Brazil, the shift in the age breakdown, with a
high health-related costs. proportionally larger older population, is a relatively
recent phenomenon. The Brazilian population has
This text outlines the need for emphasis on low- grown markedly over the past 70 years. Moreover,
complexity care, i.e., a focus on the coordination, the increase in the aged population has outstripped
prevention and monitoring of clients in an effort that of other countries.

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Contemporary care model for the elderly: the current need

The statistics show that, in 1950, the total A shortcoming of most care models is that they
Brazilian population numbered 54 million, rising to are disease-centred. Sadly, preventive actions are still
213 in 2020. According to projections, the population regarded as an overload of procedures and additional
is set to reach 229 million by 2050, and subsequently costs. However, this approach should be recognized
decline to 181 million in 2100. The absolute growth as a strategy which, over the medium-to-long term,
was a factor of 3.3 within the space of 150 years (lower can reduce admissions and other much higher-cost
than the 4.3-fold increase in the global population) procedures12.
6
. While the growth in the Brazilian population as a 3 of 20
whole was high, the increase in the older age stratum All evidence points to the fact that biomedicine-
exceeded the global average. based health systems will eventually run into
sustainability problems. This fact suggests that
Brazil must take on the task of ensuring quality programs for aged clients should be built based
of life for its senior citizens who, as per the majority around integrated care, with an active role of health
of Brazilians, have low education and poor social professionals and their team in managing not only
protection Health-wise, this group has a high the disease but the person, making judicious use of
prevalence of multiple chronic diseases7, which the available technology and of quality information
require on-going care8 placing an economic burden and routine monitoring.
on society9 due to the growing demand for health
services. Aged patients, compared with other age Medical specialists, hospital, drugs, clinical
groups, tend to have longer, more frequent, hospital tests and imaging scans are also an integral part of
stays. This situation has major economic, welfare this optimal care model, but the approach should
and social repercussions. be centred on low-complexity interventions and
follow-up of clients by their doctor13. A contemporary
This situation calls for an innovative quality health care model for the aged should incorporate
model to replace the current out-dated system
a combined flow of education actions, avoidable
which will can only serve to exacerbate the poor
disease prevention, disease onset delay, timely
care and health crisis for older patients, the age strata
treatment, and rehabilitation of health problems14. In
associated with the greatest demand and cost with
other words, a line of care for older patients that seeks
respect to healthcare.
to be effective and efficient must be underpinned
The demographic transition and improved social by a coordinated informed network and boast an
and economic indicators in Brazil, relative to previous information technology system designed and tailored
decades, has led to growth in the contingent of older to this logic.
adults and placed a greater financial pressure on
Why the gulf between discourse and practice?
public and private healthcare systems. Expansion
Before examining the care model proposed in detail,
in this stratum of the population is accompanied
a question must first be addressed. A consensus
by an increase in chronic diseases and associated
exists: all stakeholders, bar none, are in favour of
costs10; an upshot of this growth is a rise in demand
for health services which, in turn, creates a shortage this new line of care. Most, however, practice the
and/or restriction in resources. Compared to younger opposite of what they preach. A gap between the
individuals, hospital admission is more frequent narrative and practice prevails. The time for the
and hospital stays longer in the older age group, novelty and widely acknowledged clichés – even
given than diseases affecting these individuals are by those who do not practice them – is over. It is
predominantly chronic and multiple, i.e., require laudable to speak of the theoretical frameworks
constant monitoring and permanent care11. or policies promoting health aging - defined as
maintaining functional capacity and autonomy into
Evidence has shown that most public-health late-life, as well as quality of life, consistent with the
problems that affect the population, including both principles and guidelines of the Brazilian National
communicable and non-communicable diseases, are Health System (SUS) focusing on disease prevention.
in fact preventable. Prominent national and international health bodies

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Contemporary care model for the elderly: the current need

and societies have advocated this concept for many of life, care for the aged population needs to be
yearss15,16. However, the next step forward must now rethought and redesigned, with an emphasis on the
be taken17. At this juncture we must ask ourselves: older adult and their particularities. This will result
if everyone is discussing the issue and the solutions in benefits, quality and sustainability, not only for
have been put forward, why then has the situation the aged population, but for the Brazilian health
stayed the same? Why has theory not become part system as a whole7,18.
of routine practice? Why have decision-makers not
ushered in change? With a clearer of the way forward, it is time to step 4 of 20
up and muster concerted efforts that transform theory
In order for the health sector to advance, into a care model offering quality for all, including
particularly that of geriatrics/gerontology, one older population. It is an undesirable situation for
of the issues that must be tackled is distrust, the SUS to fragment or for there to be an increase
where any proposed changes tend to be initially in bankruptcies of private healthcare companies.
viewed with caution. Invariably, things which are One thing is starkly clear: for every year that goes
multifactorial and constructed over many years by, the cost of health increases while the quality of
are hard to transform. Changing a culture is no care declines. Such a system is unsustainable. It is
easy task. Another stumbling block is care quality, high time, therefore, to put into practice what all
another under-valorised aspect. This is a hugely advocate but fail to implement.
important issue which calls for greater awareness
of health professionals and society alike. Some Health can be defined as a measure of the
argue it would be too costly to apply tools for rating individual capacity to realize aspirations and
care, accreditations and certifications, yet qualified satisfy needs, irrespective of age or the presence of
services are more cost effective, less wasteful and diseases7. Thus, the need for an efficient cost-effective
deliver better care outcomes for patients. comprehensive geriatric assessment has become
increasingly pressing. The goals of this assessment
Another point to consider is the generally-held are to enable early diagnosis of health problems and
notion that caring for aged patients transcends health. to plan support services wherever and whenever
Besides diagnosis and prescription, elements such as needed to allow individuals to continue to reside
social participation, and both physical and mental in their homes. Traditional history taking, physical
activities, are crucial to maintain good functioning. check-up and differential diagnosis are insufficient to
However, difficulties remain in accepting these provide a comprehensive evaluation of the range of
actions as an integral part of care, especially in functions needed for daily living of aged individuals19.
supplemental health. There is a tendency to separate
“social” actions from “curative” actions. Health systems comprise several points of care
that do not work in an integrated fashion. In general,
And concerning the model for remunerating entry into this uncoordinated network typically
health professionals? This group is generally occurs when the client is at an advanced stage,
underpaid, so why not adopt performance-related where the “front door” tends to be the emergency
pay? Associating the discussion of outcomes with the department of the hospital. This model, besides
form of remuneration is a powerful tool incentivizing being inadequate and anachronous, has a dire
doing the right thing. Thus, pay for performance cost-benefit ratio, since it makes intensive use of
(P4P) or performance-related pay (PRP) have become highly expensive technology. Its failings, however,
synonymous for the struggle to align access with care should not be blamed on the clients, but on the care
quality. Change in the remuneration model based on model itself, which overloads the higher complexity
this new care framework, focusing on results rather levels due to a lack of care at primary levels. Home-
than volume, needs to be a win-win type model, based care may represent an alternative for some
in which all stakeholders benefit, but particularly cases. Home care should not be seen as a fad but
the patients. In order to put into practice all of as more modern modality of care14. However,
the actions needed for healthy aging with quality the advent of the modern hospital is a relatively

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Contemporary care model for the elderly: the current need

recent phenomenon in that, not long ago, care was wish to engage in. Others, on the other hand, are
traditionally administered within the home setting20. physically able to perform certain everyday tasks, but
A prospective study of disease management21 offered not to choose how, when or where to carry out these
to beneficiaries of Medicare (health insurance system activities14. Functional evaluation defines the correct
for older adults managed by the North-American stratification and allocation of the aged patient into
government) showed that actions failed to reduce the line of care required, and also allows their care
expenses22 and that physicians were unhappy with behaviour to be predicted. Functional autonomy is
the insurance providers paying the costs of disease an important predictor of health of older adults, but 5 of 20
management, possibly reducing their income, besides systematically assessing the whole elderly population
interfering in the doctor-patient relationship. using long comprehensive scales is far from ideal.

Disease management programs for aged A variety of assessment tools is available for
individuals are even more complex and have a very screening risk and organizing entry to the health
low cost-benefit ratio, given that treating a disease system, validated and translated into Portuguese. A
properly only reduces the rates of morbidity associated two-stage approach, dedicating full evaluation only
with the condition. The best option is to structure to individuals at high risk, as detected by a process of
models that work in an integrated manner and cater screening, is more effective and less painstaking. For
for the whole range of needs23. If this approach is not the first stage of rapid screening, a tool meeting the
taken, then the problem is hard to resolve, because following criteria should be employed: •simple and
other diseases and their frailties remain. Moreover, safe; short application time and low cost; • accurate
resources will not be used rationally22. for detecting the risk investigated; • validated for
use in the population and for the condition being
Epidemiological information translates to the checked3;• acceptable sensitivity and specificity; and
ability to predict events, allowing early diagnosis • have a well-defined cut-off point.
(especially for chronic diseases), delaying the onset
of these conditions and improving both quality of During the first contact, the PRISMA-7 should
life and the therapeutic approach. Determining be used, developed in Canada for screening20 risk of
health status of the aged population should consider functional loss in older adults11. Comprising 7 items,
the overall state of health, i.e., take into account a a validated, transculturally-adapted version of the
satisfactory level of functional independence, as scale for use in Brazil indicates the ideal cut-off for
opposed to merely the absence of disease. Thus, the the population to be 4 points (4 or more positive
notion of functioning can be construed as a paradigm responses). The scale requires no special materials,
for the health of older adults, representing one of the qualification or extensive training and can even be
most important attributes of human aging, since it self-administered. Application time is 3 minutes and
encompasses the interaction between physical and sociocultural and educational level do not influence
psycho-cognitive capacity to perform activities of comprehension of the questions. The PRISMA-7
daily living14,24. has been used systematically at the “front door”
to the health system in Canada and by the British
Well-being and functioning go hand in hand. Geriatrics Society and Royal College of General
They represent the presence of autonomy, individual Practitioners in the United Kingdom as a screening
decision-making ability and control over one´s tool for functional loss and frailty25.
actions, establishing and acting on one´s own
convictions and independence – the ability to carry The way forwards is to take the right steps, with
out something by one´s own means – enabling the focus centred on the most important element in
individual to take care of themselves and their life. the whole process: the patient 26. Care should be
It should be noted, however, that independence organized in an integrated fashion and treatment
and autonomy, although closely related, are separate coordinated throughout the care pathway in a
concepts24. Some people are physically dependent but network logic25,27. The model should be based on
are perfectly capable of deciding what activities they early identification of risks of frailty of the user. Once

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Contemporary care model for the elderly: the current need

risk has been identified, the priority is to intervene other wealthy countries with good quality care33
before the onset of illness, thereby reducing the – where spending on health care is larger than in
impact of chronic conditions on functioning. The developing countries22,24. Nevertheless, spending by
idea is to monitor health, not disease, within a logic North-Americans is far greater. In 2017, spending
of continued follow-up, varying only in terms of per capita reached US$ 10,224, or 28% higher than
level, intensity and intervention scenario28. in Switzerland and over double that of the UK.
These figures highlight that investing heavily in the
It is important to attain better more financially treatment of diseases does not suffice. in the United 6 of 20
economical care outcomes. This requires everyone Kingdom. General Practitioners (GPs) are special
involved to understand the need for change and allow doctors who earn a bigger salary than specialists
themselves to innovate in terms of care delivery, and are highly valued by British society. General
means of remuneration and assessment of the quality practitioners are considered the “true doctors”,
of the sector. This will result in benefits, quality and because they “know everything”. Specialists are
sustainability not only for this population group, but generally perceived as being more limited since they
also for Brazilian health as a whole13. The effects only have expertise in a single specialty.
of this change of model will be felt immediately
by users. This transformation of the health system In some countries, accreditation and assessment
toward sustainability will become evident in the of quality indicators are obligatory requisites. In
medium-term. Brazil, priority is placed on volume. A policy for
incentivizing quality is currently lacking. Patients
Under this model, the generalist physician or
do not always recognize this as a need, and both
family doctor fully handles 85-95% of their patients,
public and private health providers regard this as an
without the need for the intervention of specialists. In
extra cost. Although these needs are acknowledged
addition, this doctor can recruit health professionals
by the vast majority of health managers, little is
with specific backgrounds (Nutrition, Physiotherapy,
done to improve the situation. Thus, for a well-
Speech Therapist etc.), but it is the generalist who
structured care model19, some elements cannot be left
recommends them and performs referral 29. The
out35. In Brazil, there is an excess of consultations by
British model, the National Health Service (NHS),
specialists, because the current care model follows
is centred on the generalist doctor who has a high
the North-American logic, promoting fragmentation
resolutive capacity, called the general practitioner
of care22 . Quality care requires greater awareness
(GP),1 and a close bond with the patient 21.
from health managers and society. Some claim that
Universal access to these professionals is applying instruments to gauge service quality and
guaranteed, regardless of income or social level, akin introducing accreditations and certifications would
to the SUS30. When registering with a GP, British prove too costly, but qualified services are more
citizens receive free state medical care at health cost-effective, less wasteful and have better care
clinics manned by a team consisting of generalist outcomes for patients.
physicians and nurses. Any treatment needed, if
not extremely urgent or due to an accident, will be The model proposed here is structured around
administered at the local clinic31. By contrast, under low intensity levels of care, i.e., lower costs and
the North-American model, patients are referred consisting basically of care delivered by well-trained
to numerous specialists. These are two wealthy health professionals and involving epidemiological
countries with a long tradition in medicine. They screening instruments, besides the use of monitoring
operate, however, different systems which provide technologies24. It is paramount, especially in today´s
very different results32. world, that information pertaining to clients and
their electronic medical records are available on
A recent study involving developed countries the cloud, accessible from computers or cell phones
conducted by the Organization for Economic Co- anytime and anywhere, so that physicians and other
operation and Development (OECD), showed the health professionals may monitor the client when
difference in health costs in the US compared with necessary34.

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Contemporary care model for the elderly: the current need

A concerted effort should be made to ensure that psychologist, social worker, speech-language
patients remain within the sphere of low intensity therapist, nutritionist, physical educator and workshop
levels of care, in a bid to maintain their quality of leaders (professionals engaged in integrative dynamic
life and social participation. The target goal is to activities linked to the program). In the event that
keep over 90% of older adults within this level of user care needs are identified at other levels of care,
care36. It is argued the portfolio of clients should referrals are made to specialists but always via the
contain individuals aged 50 or older. Too young? Not generalist doctor. It is important to point out that
exactly. Although not older adults, the epidemiology the model does not retain specialists, with some 7 of 20
shows that it is from this age that chronic diseases exceptions, such as when there is a large contingent of
begin to manifest. And the earlier the structure frail individuals at a clinic. In this case, six specialized
of a model of education in health and prevention areas related to the model are recommended, because
is established, the greater the chances of success. these are part of the annual evaluations, or aiding
However, defining a cut-off from 55 or 60 years and the generalist doctor, given their specificity, demand
older is also possible. In Brazil, the status of being and high prevalence. These 6 specialties are in areas
aged is defined as occurring from 60 years onwards25. in which annual preventive and control exams are
conducted, namely: Cardiology, Gynaecology, Uro-
In this context, teams are based on a duo of proctology, Dermatology, Speech-Language therapy,
professionals: a geriatric doctor and a gerontological Ophthalmology and Otorhinolaryngology/ENT.
nurse. This pair is responsible for the health of a Notably, this last professional need not be a doctor
portfolio of around 800 clients. Working weeks are but rather a speech-language therapist. Consultation
defined at 20 hours for doctors and 25 for nurses. with the specialists listed is only possible upon request
The geriatrician performs clinical management; by the patient´s GP. Thus, if the client requires care
the nurse, specialized in Gerontology, acts as care of a given specialist, the other specialties will not
manager, monitoring the health status of users and be involved. The same reasoning applies to hospital
consolidating the role of contact person for support admission. Doctors and nurses are in charge of
and of strengthening ties with the patient´s family. contacting the physician of the hospital, to be briefed
A brief functional evaluation is carried out on the on the case, preferably seeking to ensure best care
first contact. This serves as a reference baseline for with shortest hospital stay.
monitoring and as a parameter for following the
therapy plan between different points in the system. Entry occurs via an action referred to as reception,
The care manager is tasked with overseeing the which takes place in two stages: the first stage is
transition of care between services and revaluates administrative and institutional in nature, when an
the patient´s functional capacity annually, or as and in-depth presentation of the actions proposed is
when necessary, encouraging their participation in made, with an emphasis on health promotion and
the process. The care manager´s function is key to disease prevention. Users thus have a better grasp
the model proposed and their involvement mirrors of the model and the overall dynamic of differential
that of navigator in the North-American system, care which will be offered to improve their health
a role created to help guide more frail patients. and quality of life. Moreover, participation of older
The function of navigator can be found in some users should be encouraged, because this is integral
providers/operators in the United States and their to this healthcare model18.
role is central in the present proposed framework.
According to the American Medical Association, this In the second stage of reception, the care
professional is responsible for managing the care of commences proper. As outlined previously, in order
users throughout the different levels of complexity to organize access to the levels of the model, a risk
of the health system, checking whether prescriptions identification screening questionnaire is applied: the
and orientations are being observed26. PRISMA-728. After application of this rapid screener,
the result will be stored on the information system.
Besides the geriatrician and nurse, the The patient then completes the other instruments
multidisciplinary team consists of a physiotherapist, comprising the functional evaluation. The functional

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Contemporary care model for the elderly: the current need

evaluation entails a 2-step process performed by The IVCF-20 can be applied by accessing the
employing validated reliable instruments adopted following link: https://www.ivcf20.org/.
by the leading geriatric research groups.
• Katz scale – assesses basic activities of daily
The Clinical-Functional Vulnerability Index-20 living41
(IVCF-20) measures 8 dimensions: age, self-rated
health, activities of daily living (3 instrumental and • Lawton´s scale – assesses instrumental activities42,43
1 basic ADL), cognitive status, mood/behaviour, 8 of 20
mobility (reach, grasp and pinch grip; aerobic/ • Mini evaluation of nutrition39
muscle capacity; gait and urinary/faecal continence),
• Tinetti scale – test of balance and gait44
communication (vision and hearing) and presence of
multiple comorbidities, indicated by polypathology, • Jaeger Card – assesses visual acuity45,46
polypharmacy and/or recent hospital admission.
Each question is scored specifically according • Mini-Mental State Exam (MMSE) by Folstein47
to the performance of the subject, for a total of and
40 points37. In addition to the questions, several
measurements, such as calf circumference, gait speed • Geriatric Depression Scale (GDS) by Yesavage41,48.
and weight/body mass index, are included to increase
the predictive value of the instrument 38. Scoring In addition to risk identification and screening
is categorized into 3 classifications: 0-6 points, protocols, other epidemiological instruments are
the respondent likely has low clinical-functional applied annually. The doctor is the manager of
vulnerability and does not require further assessment follow-up and also of the interprofessional geriatric
or specialist follow-up; 7-14 points, indicates increased team, performing more in-depth assessment toward
risk of vulnerability and the need for more in-depth devising an intervention plan. This information will be
assessment and attention to identify the appropriate collected and stored until the end of the care pathway.
treatment for chronic conditions; ≥15 points,20 After this assessment, an individual therapeutic plan
deemed high risk of vulnerability or existing frailty is defined that includes regular appointements18,
requiring more comprehensive assessment, ideally referral to the multidisciplinary team, community
by a team specialized in geriatric-gerontological care centres, and if applicable, assessment by specialists.
with psychosocial support5. A unique longitudinal and multi-professional
electronic medical record is then set up and used to
The group headed by Professor Edgar Moraes7,39, store information at all levels of care under the care
of the Federal University of Minas Gerais (UFMG), model, from first contact to end-of-life palliative
has made the instrument available on-line. The Lachs care. This record should contain information on
Scale is applied after the IVCF-20. This probes other the patient´s clinical history and physical exams,
areas thereby conferring further robustness to the but also includes information on daily routine,
assessment results. This strategy of using 2 of the family and social support etc. Information from
best epidemiological instruments aims to improve other health professionals such as physiotherapists,
the reliability of results. The Lachs40 Scale comprises nutritionists and psychologists etc. should also be
11 items (questions, anthropometric measurements held. Participation of the family, explanation of
and performance tests) and assesses areas commonly activities, and epidemiological screenings are other
impaired in older adults: visual acuity, hearing, upper important features of this product.
and lower limbs, urinary continence, nutrition,
cognition and affect, ADLs, home environment and Information on all procedures is fundamental to
social support. The application of this instrument allow monitoring of the client4. One of main factors
provides a rapid systematized means of identifying for controlling costs of the program is follow up at
functional domains that should be subsequently each level of care. This ensures there are no gaps
assessed in more detail to establish a diagnosis and in patient care when the case is referred to the care
plan interventions. network, tertiary care is required or hospital-level

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Contemporary care model for the elderly: the current need

treatment48 . The transition across care levels is forward this to the nutritionist33, who can then check
overseen by the management team, which strives whether the meal is balanced, contains adequate
to maintain a smooth flow of information, liaising dietary fibre etc. Although extremely simple, these
with assisting professionals and seeking to adhere to actions confer great trust, making the client feel
the principle of management predominantly by the protected and valued from day one. The information
geriatrician-nurse pair. The control of hospitalization system, which commences with registration of the
takes place via a flow to aid the client, ensuring that beneficiary, is one of the pillars of the program. Via
the health professionals assigned to the case are aware the system, the entire care journey will be monitored 9 of 20
of the patient´s clinical and therapeutic history, as well at each level, checking the effectiveness of actions
as the understanding that the individual has frequent and contributing to decision-making and follow-
follow-up and is set to return to their health team up. This entails a unique electronic record that is
when the clinical condition has been controlled49. longitudinal and multi-professional, and accompanies
the client from initial reception, providing an integral
In the event of hospitalization, patient monitoring assessment of the individual.
is performed daily on 2 fronts. For the first, the
nurse keeps in touch with the family to provide In the proposed model, contact with the client
support, clarification or to identify needs (pertaining can be increased, since, besides face-to-face meetings,
to patient or family). The other front involves the consultations via telemedicine are also incorporated52.
prevention manager who provides liaison between The aim is not to replace encounters in person, but to
the outpatient clinic and hospital, performing daily introduce flexibility and convenience for scheduling
follow-up with the attending hospital physician. times and days for consultations, given that neither
In hospitals which have internists, this contact is the doctor (or nurse) nor the patient need travel to
facilitated and direct. In other hospitals, support is attend the session. The drive for innovation and
provided by medical auditors or by the care team. use of the latest technology provides closer contact
Thus, when the older adult needs to be admitted of the health team with the client and family
to hospital, this takes place more quickly, avoiding members. With a platform specifically designed
unnecessary procedures or admission to intensive for this care, the contact of gerontologists will be
care, ensuring post-discharge transfer 25 to low increased, enabling numerous individual or group-
intensity level care settings, without the need to based actions involving a nutritionist, psychologist
consult several specialists50. This all culminates in or physiotherapist, with counselling and broader
higher quality care, with a significant cost saving and contact with clients. Besides the interdisciplinary
positive impact on the medical loss ratio51. team which delivers care directly, the model boasts
a team of doctors and nurses working virtually.
A high-quality information system and The GerontoLine relationship channel guarantees
lightweight technology is essential in helping to win the users full-time coverage. In passive mode, this
the confidence of clients. Without using technology, receives calls from clients for guidance; in active
this project cannot go forwards and thus competence mode, the team contacts patients on a regular basis
is needed to use it to the full. For example: the client, keeping them on the care radar. Favouring this
upon reaching the front-door of the health centre, may interaction, the professionals coordinating care
undergo facial recognition which then automatically (online) have access to the key information help in
brings up their medical record at the reception each patient´s medical history.
desk. When receiving the client, the receptionist
addresses them by name, enquires after the family GerontoLine differs from call centres,
and checks the list of medicines they are using. commonplace in traditional health services and
Another important feature is the availability of a which typically operate with poorly-trained staff
cell phone app containing individualized information who have a reputation for overuse of clumsy “gerund
and reminders for appointments and prescribed phrases”5 and offer no support if the client´s question
actions. The app can, among other functions, request or query falls outside the script. With GerontoLine,
the client to take a photo of their breakfast and which is available 24 hours a day, 7 days a week, the

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Contemporary care model for the elderly: the current need

call is answered by trained health professionals who consultations per month, giving a total client
have access to the patient´s records and, thus, have portfolio of 800 users seen over a 4-month period.
everything at their disposal to resolve problems53.
Should an ambulance need calling in the middle There is also the novel comprehensive (multi-
of the night, this professional handles the whole dimensional) geriatric assessment instrument
referral process. In the event of a call during the (CGA)56, that prescribes application of the IVCF-
early hours, this attendant will send a message out 20 (Clinical-Functional Vulnerability Index-20)
to the doctor, explaining the reason for contacting performed by any health professional, including 10 of 20
them. Hence, first thing in the morning, the doctor nursing assistants/technicians, community health
can take the first measures necessary. In other words, workers or, alternatively, by patient caregivers.
the patient and their family members feel protected, Application time is short, taking 5-10 minutes
since they know that if needed, there is a qualified depending on the evaluator´s experience and patient´s
telephone service available to them. In order for the level of frailty. The questions are directed at the older
GerontoLine to work smoothly, a comprehensive adult, with responses confirmed by a family member
patient record is required54 which documents not or companion that lives with the respondent or is in
a position to vouch for the answers. In cases where
only clinical issues, but also behavioural, social and
the older adult is unable to answer, the caregiver
family aspects, where a global view of client needs
responses are used. The instrument is applicable to
are necessary for this model. Another benefit is
any aged person, irrespective of their health status,
the epidemiological assessment instruments which
and in any care setting (outpatient clinic, LTCF,
are applied at the first consultation, and repeated
hospital, home, etc.). The instrument contains 20
annually thereafter, or sooner if a special need arises.
questions assessing the main health dimensions of
The geriatric doctor is responsible for physician older adults. Questions should be sequenced and
actions and metrics: asked in a systematized fashion. Each question-
response carries clinical meaning and, if answered
• managing the health history of their portfolio of positively, should be followed by advice on the issue
clients, devising tailored personalized care plans; flagged.

• defining clinical risk of patients in their portfolio The frailty risk factor defines the number
and handling their care needs in conjunction of consultations for the year. The number of
with the nurse; consultations by the doctor varies according to the
prior assessment at the time of collection, whereby
• monitoring hospital admissions; the number of annual visits shall be defined by
level of need, based on results of epidemiological
• assessing and processing need for referral to screening. Some visits may be brief, or even via
specialists; and software app, to clear up a specific query for example,
where, besides the doctor, the patient is supported
• coordinating and discussing most challenging by the whole health team. The other gerontologists
clinical cases so as to integrate and align the team in the team see clients referred by the doctor-nurse
regarding the most appropriate care approach duo for one-on-one or group-based sessions. The
for each case. client´s family members may also be contacted by
the gerontologist to broaden support and assistance.
Based on a standard 20-hour working week,
each doctor does four 5-hour shifts per week. Nurse actions and metrics. The remit of the nurse
During each shift, a total of 12 patients can be covers 4 different actions that are integral to the
seen with consultations lasting 20 minutes each, process as a whole:
with 3 “floating” slots (60 mins), used for covering
additional task demands, such as cross-checking with • brief functional assessment – at patient´s first
the nurse, case review55 or contacting hospitalized consultation (performed by the nurse), during
patients. Thus, the doctor performs around 200 which the screening tests are applied. Taking

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Contemporary care model for the elderly: the current need

of clinical history and the “bond” between the their health. Patients will be contacted more often
individual treated and treating commences57,58 according to their level of frailty. However, the entire
portfolio of clients will be monitored at least once a
• nursing consultation – the frequency of visits will month. Contact will be made by phone or via the app
be determined according to the level of frailty, according to a structured protocol to ensure effective
classified as: interaction and that the health history and electronic
data of beneficiaries are duly updated to optimize
- Risk 1 – appointments scheduled every 4 months; 11 of 20
access by health teams and beneficiaries alike.
- Risk 2 – appointments every 3 months; and Assisting in the monitoring process, the professionals
from the service, via web or telephone, perform
- Risk 3 – appointments every 2 months. monitoring and also make themselves available to
users for virtual sessions.
During consultations, the nurse must:
Fee for service. The prevailing hegemonic
• assess the meeting of goals set; model for payment of health services in many
countries, both within public systems and private
• establish new goals, as necessary; and health plan market, is the fee-for-service (or pay-
for-performance) model. This is characterized by
• screen for needs requiring medical intervention,
stimulation of competition by users and payment
engage benef iciaries in developing an
for the number of services delivered (volume). There
individualized care plan outlining and addressing
is no use changing the payment model59 without
their needs and priorities, in addition to ensuring
also changing the care model and vice-versa, since
the beneficiary and their family understand their
the two are interdependent. Some of the flaws in
role in promoting care and feel confident to
the Brazilian health system (especially supplemental
exercise their joint responsibilities.
services) which largely affect older users are the
Concomitantly, the nurse can identify barriers of result of the decades-old model adopted. In order
a psychological, social, financial or environmental to cater to the new pressing demand from society,
nature affecting the ability of the beneficiary to alternative models of pay need to be implemented to
adhere to treatment or promote health, devising a break the vicious circle of fragmented consultations
strategy which resolves or attenuates the issue at hand. out of step with the social and health situation of
Also within this remit, the nurse can organize group older adults, as well as the ordering of procedures
sessions, or therapeutic groups, bringing patients with unrelated to the desired outcome36.
the same condition together promoting information
dynamics and awareness of health practices. The Performance-related pay is remuneration based on
nurse is also available for unscheduled face-to-face results attained over a given period. Because technical
consultation without prior appointment for patients and behavioural standards required of professionals
who, via GerontoLine, request assistance and under this model are high, the payment is intended
guidance. These interactions are referred to as Brief to compensate for this high level of performance.
Nursing Interventions. These are not emergency Fee-for-service has bonus rates as high as 30% on
visits but are aimed, among other objectives, at top of base salary for the quarter. Every 3 months, an
preventing unnecessary use of emergency services. appraisal of the professional´s performance is carried
Given that the majority of complications received by out based on previously established indicators. Given
telephone or via call centres are handled virtually or a total of 4 medical consultations per year should be
referred12 to emergency services, the time set aside in provided under the program criterion, 1 consultation
the professional´s schedule for this action represents per quarter for every client in the doctor´s portfolio
10% of each work shift. is expected. Professional diligence and good time-
keeping are pre-requisites for awarding bonuses and
Lastly, monitoring is aimed chiefly at keeping the are fundamental for guaranteeing the number of
patient under the watchful eye of the duo managing consultations - a key performance indicator for service

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Contemporary care model for the elderly: the current need

operation. Another eligibility criteria for the points participants. Topics discussed are chosen according
program for bonus awards is proper registration of the actual needs of the portfolio of clients.
information for each patient, including any hospital
admissions. These stays constitute the main cost For physiotherapy, enrolment occurs through
factor, where strict control by the team is key to the medical referral with a clinical diagnosis.
economic-financial success of any initiative or project. Physiotherapeutic assessment is done using a
structured questionnaire and the Tinetti scale. The
Another basic principle is the geriatric doctor´s aim is to identify musculoskeletal changes which result 12 of 20
ability to resolve cases. According to international in functional limitations and to define an adequate
studies31, generalist physicians can resolve 85-95% treatment program, albeit individual or group-based.
of their clientele´s clinical issues. Referrals to clinical The objective of the therapeutic procedures is to
specialties are the exception. If the doctor refers no improve quality of life, reduce pain and risk of falls,
more than 15% of the clients from their portfolio enhance mobility and movement, as well as to treat
within a given quarter, this indicates good case- orthopaedic trauma-related injuries, neurologic
resolving ability and eligibility for bonus points. complications and rheumatological diseases.
The engagement of users of the program by
multidisciplinary team and the Community Centre The nutritionist sees patients referred from
provides a measure of the bond with the client and the geriatrics service. This professional carries
resolutive capacity. Hence, an item was included that out an assessment of the client based on clinical,
rates participation of members of each portfolio biochemical, anthropometric and dietary data,
in consultations with the team gerontologists examining functioning, eating and life habits
and in group activities at the Community Centre, (past and present), sensory deficit, changes in
contributing further points toward bonus awards. gastrointestinal and behavioural changes, among
Medical loss ratio is the main economic-financial other aspects with the potential to impair food intake
indicator for assessing the program, with a and, consequently, nutritional status. Information on
commensurately higher weighting attributed to this family organization and care, income, and place of
item, and for which the physician can be awarded up residence is also collected. At the first consultation,
to 2 points on their performance appraisal. The goal an in-depth dietary anamnesis is performed to
is excellence in care provision, so it is only fair to corroborate the other information contained in the
incentivize the professionals as part of the win-win patient´s medical record.
premise. Other means of rewarding performance
include granting time off, book purchases and Workshop leader is the term typically used to
funding post-graduate courses. There is no doubt that refer to the instructors of activities performed daily
performance-related pay models will be introduced within the setting of the Community Centre. These
in Brazil. Professionals in the health sector should professionals are gerontologists specialized in their
start entertaining this notion more as a question of field of practice. A schedule of weekly activities is
how this will roll out, as opposed to when or whether offered to the clients, who can choose those which
this will take place28,60. interest them most. Clients can take part in more
than one activity, depending on demand.
Therapy groups are a group-based intervention
strategy involving patients who have the same Assessment of activities of daily living (bathing,
disease. Through discussion circles and interactive toileting, transferring, continence and feeding),
presentation, participants have the chance to better instrumental ADLs (using the telephone, shopping,
understand the disease in questions and clear up preparing meals, handling medications and finances)
doubts, representing a self-preventive action. The and mobility (balance, gait speed and limb strength)
duration of these group meetings depends on the can contribute to generate important information
subject being addressed. In each shift, 60 minutes for decision-taking, mapping individual protection
are dedicated to this action, convening 5 to 10 and risk factors61.

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Contemporary care model for the elderly: the current need

The medical-health activities of health education family ties, community involvement and prevention
can broaden its focus of attention to encompass of situations of social risk for individuals aged ≥
positive dimensions of health beyond controlling 60 years65. The programs, besides offering physical
specific diseases62 . Screening of hearing/vision, exercise, feature cognitive training, nutritional
and help in management of the use of multiple programs66, telephone services, computing, home
medications (polypharmacy) precede the detection security, fall prevention, urinary/faecal continence,
of problems, contributing to care. Health habits immunizations and financial management. Care
(protective factors) include balanced diet, regular with mobility of older adults, fall prevention and 13 of 20
physical exercise, stimulating social interaction, balance in workshops for psychomotricity, strength
occupational activity and well-being actions in training, advice on choice of footwear and podology
the field of nutrition (cuisine for diabetes and service, are all important because they help maintain
osteoporosis, for example)45. independence67.

Community centres. With the steady growth Aging requires adaptation. New learnings serve as
in the older population, some education programs a resource for maintaining functioning and flexibility
focused on leisure have been developed. The first of older adults68 . Art, cultural and recreational
Brazilian experience of education for middle-aged activities are traditionally associated with community
and older adults was implemented by the Social centres for older adults and represent important
Service of Commerce (SESC) in the form of sources of pleasure: general knowledge, languages,
community groups. These groups emerged in the information technology, composing texts and reading,
1960s running programs centred around leisure patchwork art, ballroom dancing, music, card games,
activities. These were welfarist in nature in as far dominoes, chess, meditation and sightseeing trips. As
as they did not offer the tools needed for subjects a tool for planning aging, there is the Time Trade-Off
to regain the desired autonomy. From the 1980s, questionnaire, which allows a negotiation between the
universities began to provide educational programs health professional and older individual, considering
for the older population and for professionals wishing risk and pleasure. Many retirees rejoin the job market
to study aging-related issues, predominantly offering on a regular or sporadic basis, whether for pleasure or
education, health and leisure63,64. Similar centres had due to necessity, topping up income and stimulating
also been set up by health maintenance organizations social contact.
following the release by the National Agency of
Supplemental Health (ANS) of the Care Plan for In the USA, many dedicate time to voluntary
Older Adults in Supplemental Health. The document projects. Community centres can provide legal
sets out incentives to foster a change in the care logic, aid services, a caregiver agency and help for the
providing opportunities for health promotion for housebound (support for ADLs, remote assistance
older adults. A resolution was also published which and meal deliveries etc.). To this end, investment in
encourages health plan beneficiaries to take part in courses for training caregivers and in communication
active aging programs, in exchange for discounts in the care network are essential. Also, regularly
on their monthly fee61. frequenting workshops allows the aged person to
experience a routine, which also benefits the caregiver
The setting up community centres is in line who is freed up to engage in other activities. An
with the National Health Policy for Older Adults annual or six-month “contract” for older adults to
(Regulation no. 2528, of 19th October, 2006). attend workshops, as they see fit and subject to the
The primary goal is to recuperate, maintain or availability of coordinators, facilitates management.
promote autonomy and independence of older The centres can also provide a forum for discussion
individuals, as well as foster active healthy aging, of issues affecting the older individual.
with encouragement to participate and boost social
interaction. The centre offers a range of activities Aging and end-of-life warrant focus. A practical,
which contribute to healthy aging, development of light-hearted guide can be devised addressing
autonomy and social interaction, strengthening of frequently asked questions in relation to aging

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Contemporary care model for the elderly: the current need

(e.g., “what is happening to me?”). Philosophy and approach, that Community Centres have found their
religion can contribute to reflection on aging and place based on the premise that whoever works
death. According to Plato, in Ancient Greece, to with the perspective of respecting the needs of aged
philosophize was akin to learning how to die. An individuals respects their own future.
idealist, he believed in life after death, regarded this
as a passage, a liberation of the soul. For materialists, Amid the need to devise multiple support
however, such as Epicurus, life was finite, making strategies for those needing protection and care, a
it even more valuable. One cannot live the same question emerges: who is charged with caring for 14 of 20
way when believing in such different conceptions of children and older adults? In order to answer this
death69. End-of-life, palliative care and the way we question, parallels must be drawn between these
culturally cope with this stage of life were examined ages. In the line of care during the human life cycle,
in a previous study26. Would it be feasible to prepare childhood and old age share similarities. Young
a practical, yet sensitive, guide presenting some ideas children, people with chronic diseases and aged
about death? Psychology, based on a discussion individuals – in fact, all those with limited autonomy
about ties, can help toward this task. Letting go of and independence – require special care. Public
perfect hair colour, eyesight and hearing, letting go entities, such as crèches and community centres,
of power and memory; allowing decline, accepting can add to the options of support and monitoring,
the “exoskeleton” (prostheses, hearing aids, glasses, intergenerational care approaches and broaden
implants.); finding solutions, transforming and patterns of social integration. Expansion of support
refining. Dealing with the fears as a group is fruitful, networks and of resources to deal with limitations
but older adults are charged with the task of letting go, enriches the life experience.
experiencing loss, saying farewell. Human loneliness
is a fact and a necessary one. Many families are tasked with looking after
children and old people. With the advent of pensions
However, the Community Centre can help to in the 20th century, these families began sharing
reflect on the meaning of life, every life, by cultivating this responsibility with companies and the state. The
individual stories in accounts enriched with photos, building of care networks represents a considerable
scenes from films, songs, food recipes, sharing meals relief for families, increasing their chances of meeting
etc. The human journey throughout the life span is
the challenge of their responsibilities. However,
a cultural construct that is experienced in a singular
power exists in all human relationships. How can
fashion. Each phase determines and predicts the
others be empowered while avoiding a relationship
possibilities of the next: we age as we live.
of guardianship? How can a situation be avoided
Flexibility and resilience (ability to cope whereby caring becomes an act of domination?
with events) differs from person to person. The It is paramount to manage the realm of power
experience of ageing is both heterogeneous and present in all relationships carefully and to reject
multidimensional, thus calling for singularity also in strategies of domination. Relationships based on
care plans70. When dealing with minor stressor events dialogue, a person-centred approach, negotiation,
in daily life, we draw on personal resources, including and co-responsibility make all the difference. It is
social resources. The importance of solidarity and important to discuss the question of the quality of
sharing experiences is relevant for older adults and the caregiver/care recipient relationship, as well as
those around them. The quality or functioning of the possibilities of transforming the relationships of
social support is more important for adaptation of power. At community centres, studies recommend
older adults than the number of people in the network the use of measures of quality of life based on self-
or the frequency of contact71. Indeed, the association rating by the users: “how would you rate today?”.
between social support and self-care supports this This approach boosts self-esteem, instils a sense of
notion32 . It is through this goal of valorising and governability and contributes to the devising of a
respecting old age, fostering an effective embracing personalized care plan every day64.

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Contemporary care model for the elderly: the current need

Such centres can provide the incentive for older intervention, triage, screening, early detection,
adults to go out regularly and offer the opportunity comprehensive geriatric assessment, and functional,
of social contact. Community centres can also social (networks) and emotional (ties) assessment.
stimulate the formation of a communication network The older age group is increasing and growing older,
centred around care, forging a relationship of trust baby-boomers are reaching the “third age”. Life
between the older adult, their family members and expectancy continues to rise. This is accompanied
professionals from the institution. The existence by a growth in the care technology pertaining to
of shared spaces to exchange information and this stage of life, which can now span 40 years. 15 of 20
experiences, as well as everyday informal interactions, Community centres need to both increase in number
help bring interlocutors together. In the care network, and recognition. Solutions are mixed: individual and
the role of different actors should be discussed and singular, but also collective.
negotiated on an on-going basis, given their needs and
possibilities also undergo change. To this end, forums For a long period, the crèche institution
of communication, as well as groups for reflection evoked a certain distrust, being associated with an
and conversation circles, reaffirm the importance orphanage, a place where children were abandoned64.
of collective construction (older adults, caregivers Institutions which care for older adults for some
and professionals) of the daily routine. Workshop hours of the day, such as community centres may
leaders should be trained and integrated based on also conjure connotations of old people´s homes,
the premises of accompanying human aging. nowadays referred to as long-term care facilities, and
sometimes identified as places where elderly are left
In the Berlin Aging Study72 , an extensive and abandoned. Today, there is prevailing consensus
interdisciplinary study involving 516 randomly on the importance of socialization of young children.
selected older adults aged 70-100 years conducted Similarly, the important role of community centres
in the city of Berlin, Germany between 1990 and in preventing social isolation of older adults is
1993, different variables were analysed, including clear. There is a tendency for older individuals
medical (functional capacity, risk profile, reference to have fewer social contacts and relationships.
biological values), sociology and social policy (life Frequenting the institution also provides routine
history and generational dynamic, family structure and rhythm, conferring structure to their everyday
and dynamic, economic situation and social security, lives. Sociability networks of older adults can occur
social resources and social participation), and also in different settings: squares, beaches, clubs and
psychology parameters. In community centres, religious activities, or in collective entities such as
cohort studies can contribute to the knowledge and community centers64.
organization of care of the group of older users.
Institutions that host older residents, albeit short
In the USA, there are cohorts of older adults or long-term, may be part of an external network,
who frequent community centres during the course forming venues of interaction. Receiving external
of aging. The epidemiologic information obtained family members and older adults for activities
enables health to be monitored and problems together with the older residents, provides the
detected early or avoided, with the goal of extending interaction and workings of a support network51. This
the healthy life of older adults28,58. At these centres, can be exemplified by a German experience which
multiple dimensions of care can be observed through promoted, within the same building, a community
leisure-time and instrumental activities. Programs centre running daily activities for older adults, health
for health promotion and disease prevention are run services (outpatient clinics and day-care hospital),
within Brazil and worldwide to raise awareness on care for housebound individuals and long-term care
health care of the older population. These initiatives facility. Preventing disability and recouping autonomy
provide a basis for important debates71. through rehabilitation programs – all or a combination
of these forms of care under the same roof – are
The field of public health encompasses access actions which widen the range of possibilities. He
to information, risk protection factors, early pre-old, young-old and oldest-old all experience

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Contemporary care model for the elderly: the current need

similar situations which often precede different consolidate the structuring of the care model for
stages of limitations in functioning. Resources and older adults. I often receive comments of praise, yet,
solutions also multiply, in as much as autonomy and these are invariably tempered by the remark: “what
independence also change during this phase73. you write is so obvious that maybe this is why it´s so
hard to put these ideas into practice¨. I tend to agree.
Care centres may provide a range of care for And it is precisely because I realize these reforms are
children, individuals with temporary or permanent increasingly imperative with each passing year that,
disability and older individuals, with or without that I am again bringing this matter to the attention 16 of 20
autonomy and independence. Crèches, when opening of academics and opinion leaders in the health sector,
their doors to older visitors for activities together because a further dose of medicine is sorely required
with the children, provide interaction and allow which, it is hoped, will be able to remedy the present
affective ties to form between generations74. The ailing care model.
conveying of values, life stories told in photos, recipes
or songs and sharing meals together, for example, Population aging is accompanied by new
value the older generation, conferring a place of demands, and challenges the traditional care model.
importance and acting as a motivator. Fostering Advancements in technology, science and medicine
ties and the ability to pay attention to one another, offer those who embrace the modern tools for
is a natural consequence of these shared activities. maintaining health the chance to enjoy life for longer.
The social and economic transformations of the last
Birthplace of the model was developed within the few decades, their consequent shifts in behaviour
Open University for the Third Age of the University
of contemporary society – changes in eating habits,
of the State of Rio de Janeiro (UnATI/UERJ)8, an
increased levels of sedentarism and stress – and
institution set up 30 years ago that has gained national
growing life expectancy of the population, have
recognition as one of the most important health
contributed to higher rates of chronic diseases,
programs for middle-aged and older adults36,75. This
posing a major public health problem. The health
initiative has also garnered international awards and
needs of the older population cannot be satisfactorily
been endorsed by the World Health Organization.
met until it is recognized that this stratum of society
requires specific care. This makes overhauling the
current health model an imperative. Scrutiny of the
CONCLUSION
national health budget reveals that the vast bulk
An innovative quality care system must be built, of funds is dedicated to hospitals and equipment
because the prevailing out-dated care model, will only for performing complementary exams. Society and
exacerbate the current poor service and healthcare health professionals alike, as a general rule, adhere
crisis, particularly for older adults, the age group to a “Hospítal-centric” logic, with a mind-set of only
placing the greatest demand and cost on the system. treating diseases as opposed to preventing them. A
contemporary care model for older adults is a current
In recent years, I have been dedicated to researching need and urgent imperative for the decades ahead.
the integral care of older adults and refinement
of care models. In the capacity of Director of the The ideal care model for the older population
Open University for the Third Age of the University should be centred on identifying potential risks.
of the State of Rio de Janeiro (UnATI/UERJ), a Monitoring health instead of disease will direct
centre for studies, education, debates, research and investment toward early prevention, resulting in a
assistance addressing issues inherent to aging, which better chance of rehabilitation and reduced impact on
has contributed to a change in mind set of Brazilian functioning. As a response to the older population,
society regarding its attitudes to older generations, and more actions focused on health promotion and
my role as Editor-in-Chief of the Revista Brasileira de education, the prevention and delaying of disease
Geriatria e Gerontologia (RBGG-Brazilian Journal of and frailty, besides maintenance of independence and
Geriatrics and Gerontology), beyond mere opinion, autonomy, should be implemented. Lastly, increasing
I have personally witnessed the desire and need to longevity alone does not suffice. It is vital that these

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Contemporary care model for the elderly: the current need

additional years can be lived with quality, dignity is required, along with a doctor who knows their
and wellbeing. A novel approach to health care that patient well, working in unison with a health team,
promotes quality of life for users – albeit under the not seeking to cure their client but rather stabilize
SUS or via the private sector – will entail the use their health so they may live older age to the full!
of qualified well-prepared professionals, integrated
care, and judicious deployment of information
technology. This is the shape that contemporary AUTHORSHIP
resolutive models advocated by leading national and 17 of 20
international health organs should take. And this Renato Peixoto Veras - responsible for all aspects
is what we wish to see in the not-so-distant future. of the work, ensuring that issues related to the
accuracy or integrity of any part of the work
Against this backdrop, the goal is to provide older
users with the best care. To this end, monitoring Edited by: Luiz Antonio Tarcitano

REFERENCES
1. Veras RP, Ramos LR, Kalache A. Crescimento 7. Veras RP, Estevan AA. Modelo de atenção à saúde
da população idosa no Brasil: transformações e do idoso: a ênfase sobre o primeiro nível de atenção.
consequências na sociedade. Rio de Janeiro, Rev. In: Lozer AC, Leles FAG, Coelho KSC (org).
Saúde Pública. Jun. 1987, Rio de Janeiro, 21(3):225-33. Conhecimento técnico-científico para qualificação da
https://doi.org/10.1590/S0034-89101987000300007 saúde suplementar. Brasília, DF: OPAS, 2015. p. 73-84.
WORLD HEALTH ORGANIZATION. Ageing:
8. Moraes EN, Reis AMM, Moraes FL de. Manual de
World Report on Ageing and Health. Geneva: WHO;
Terapêutica Segura no Idoso. Belo Horizonte: Folium,
2015. WORLD HEALTH ORGANIZATION.
2019. 646p.
Global status report on noncommunicable diseases
2010. Geneva: WHO; 2011. 9. Szwarcwald CL, Damacena GN, Souza Júnior PRB
de, et al. Percepção da população brasileira sobre
2. Kalache A, Veras RP, Ramos LR. O envelhecimento
a assistência prestada pelo médico. Ciênc. Saúde
da população mundial: um desafio novo. Rev. Saúde
Colet. Fev 2016;21(2):339-50. Available in: https://
Pública. 1987. Rio de Janeiro: 21, (3): 200-210. https://
doi.org/10.1590/1413-81232015212.19332015. Cited:
doi.org/10.1590/S0034-89101987000300005
2021 Nov. 01.
3. Ramos LR, Veras RP, Kalache A. Envelhecimento
10. Veras RP. A contemporary care model for older
populacional: uma realidade brasileira. Rev. Saúde
adults should seek coordinated care, grater quality
Pública, Rio de Janeiro, v. 21, n. 3, p. 211-224, 1987.
and the reduction of costs. Int J Fam Commun Med.
https://doi.org/10.1590/S0034-89101987000300006
2019b;3(5):210-14. DOI: 10.15406/ijfcm.2019.03.00159
4. António M. Envelhecimento ativo e a indústria da
11. World Health Organization, World Health Statistics
perfeição. Saúde e Sociedade, São Paulo, v. 29, n. 1,
2011. Available in: https://www.who.int/docs/default-
p. 1-10, 2020. Available in: https://doi.org/10.1590/
source/gho-documents/world-health-statistic-reports/
S010412902020190967. Cited: 2021 Nov. 15.
en-whs2011-full.pdf. Cited: 2023 Sept. 25.
5. São José J de, Teixeira AN. Envelhecimento Ativo:
12. Veras RP. New model of health care improve quality
contributo para uma discussão crítica. Anál. Soc.,
and reduce costs. MOJ Gerontol Ger. 2019a;4(4):117-
Lisboa, v. 49, n. 210, p. 28-54, 2014. Available in:
120. DOI: 10.15406/mojgg.2019.04.00191
http://www.jstor.org/ stable/23722984. Cited: 2021
Nov. 20. 13. Caldas CP, Veras RP, Motta LB, et al. Atendimento
de emergência e suas interfaces: o cuidado de curta
6. United Nations, Population Division, World
duração a idosos. J. Bras. Econ. Saúde. 2015;7(1):62-69.
Population Prospects, New York, 2019. Available in:
https://www.un.org/development/desa/pd/news/ 14. Veras RP. O modelo assistencial contemporâneo
world-population-prospects-2019-0. Cited: 2023 e inovador para os idosos. Rev Bras Geriatr
Sept. 26. Gerontol. 2022;25(3):1-13. e200061. https://doi.
org/10.1590/1981-22562022025.230065.pt 2020b.

Rev. Bras. Geriatr. Gerontol. 2023;26:e230233

Contemporary care model for the elderly: the current need

15. Carvalho VKS, Marques CP, Silva EN. A 26. Veras RP, Gomes JAC, Macedo ST. A coordenação
contribuição do Programa Mais Médicos: análise a de cuidados amplia a qualidade assistencial e reduz
partir das recomendações da OMS para provimento custos. Rev. Bras. Geriatr. Gerontol 2019;22(2):1-13.
de médicos. Ciênc. Saúde Colet. 2016;21(09):2773-87. https://doi.org/10.1590/1981- 22562019022.190073
https://doi.org/10.1590/1413-81232015219.17362016.
27. Moraes EN, Moraes FL de. Avaliação
16. Veras RP, Oliveira M. Linha de cuidado para o idoso: Multidimensional do Idoso. 4 ed. Belo Horizonte:
detalhando o modelo. Rev. Bras. Geriatr. Gerontol. Folium, 2014.
2016;19(6): 887-905. https://doi.org/10.1590/1981-
28. Folstein MF, Folstein SE, McHugh PR. “Mini-mental 18 of 20
22562016019.160205.
State”. A practical Method for grading the cognitive
17. Veras RP. Caring Senior: um modelo brasileiro de state of patients for the clinician. J Psychiatr Res
saúde com ênfase nas instâncias leves de cuidado. 1975;12(3):189-98. doi: 10.1016/0022-3956(75)90026-6.
Rev. Bras. Geriatr. Gerontol. 2018;21(3):360-66.
29. Lima-Costa MF, Veras RP. Saúde pública e
DOI:10.1590/1981-22562018021.180100.
envelhecimento [editorial]. Cad. Saúde Pública,
18. Moraes EM organizador. Princípios básicos de 2003;19(3):700-01. https://doi.org/10.1590/S0102-
geriatria e gerontologia. Belo Horizonte: Coopemed; 311X2003000300001.
2009. 700 p.
30. Castro MC, Massuda A, Almeida J, et al. Brazil’s
19. Veras RP, Caldas CP, Lima KC de, et al. Integração unified health system: the first 30 years and prospects
e continuidade do cuidado em modelos de rede for the future. Lancet 2019;394(10195):345-56. doi:
de atenção à saúde para idosos frágeis. Rev. Saúde 10.1016/S0140-6736(19)31243-7.
Pública 2014;48(2):357-365. https://doi.org/10.1590/
31. Turner G, Clegg A. Best practice guidelines for the
S0034-8910.2014048004941.
management of frailty: a British Geriatrics Society,
20. Saenger ALF, Caldas CP, Motta LB. Adaptação Age UK and Royal College of General Practitioners,
transcultural para o Brasil do instrumento PRISMA-7: report. Age Ageing 2014;43(6):744-7. https://doi.
avaliação das equivalências conceitual, de item e org/10.1093/ageing/afu138.
semântica. Cad. Saúde Pública, 2016;32(9):1-7. https://
32. Veras RP. The Current Challenges of Health
doi.org/10.1590/0102-311X00072015.
Care for the Elderly. J. Gerontol. Geriatr. Res
21. Tanaka OY, Oliveira VE de. Reforma(s) e 2015b;4(3):1-13. https://doi.org/10.4172/2167-
estruturação do Sistema de Saúde Britânico: lições 7182.1000223. In: Veras RP. Bem Cuidado: um
para o SUS. Saúde Soc 2007;16(1):7-17. https://doi. modelo integrado com ênfase nas instâncias leves de
org/10.1590/S0104-12902007000100002 cuidado. Rio de Janeiro: ANS, 2018a.
22. 22. Oliveira M, Veras RP, Cordeiro HA et al. A 33. Machado RSP, Coelho MASC, Veras RP. Validity
mudança de modelo assistencial de cuidado ao idoso of the portuguese version of the mini nutritional
na Saúde Suplementar: identificação de seus postos- assessment in brazilian elderly. BMC Geriatr
chave e obstáculos para implementação. Physis 2015;15:132. doi: 10.1186/s12877-015-0129-6.
2016;26(4):1383-94. https:// doi.org/10.1590/S0103-
34. Veras RP. An Innovative Healthcare Model for the
73312016000400016.
Elderly in Brazil: Care Coordination Extends Care
23. Geyman JP. Disease management: panacea, another Quality and Reduces Costs. Int. J. Intern. Med.
false hope, or something in between. Ann. Fam. Med Geriatr 2019c;1(2):33-42.
2007;5(3):257-60. doi: 10.1370/afm.649.
35. Pedro WJA. Reflexões sobre a promoção do
24. Porter ME. A strategy for health care reform: toward Envelhecimento Ativo. Kairós 2013;16(3):1-24.
a value-based system. N. Engl. J. Med 2009; 361:109- https://doi.org/10.23925/2176- 901X.2013v16i3p9-32 .
112. DOI: 10.1056/NEJMp0904131.
36. Oliveira M de, Veras RP, Cordeiro HA. A importância
25. Lima KC, Veras RP, Caldas CP et al. Effectiveness da porta de entrada no sistema: o modelo integral de
of intervention programs in primary care for the cuidado para o idoso. Physis 2018;28(4):7-18. https://
robust elderly. Salud Pública México 2015;57(3):265- doi.org/10.1590/S0103-73312018280411
74. In: Lima KC, Veras RP, Caldas CP et al.
37. Chultz MB, Kane AE, Mitchell SJ et al. Age and life
Health Promotion and Education: a study of the
expectancy clocks based on machine learning analysis
effectiveness of programs focusing on the aging
of mouse frailty. Nat. Commun 2020;11(4618):1-10.
process. Int J Health Serv 2017 Jul;47(3):550-70. doi:
https://doi.org/10.1038/s41467-020-18446-0.
10.1177/0020731416660965.

Rev. Bras. Geriatr. Gerontol. 2023;26:e230233

Contemporary care model for the elderly: the current need

38. Moraes EM. Atenção à saúde do idoso: aspectos 50. Lima-Costa MF, Barreto SM, Giatti L. Condições
conceituais. Brasília, DF: OPAS, 2012. 98p. de saúde, capacidade funcional, uso de serviços de
saúde e gastos com medicamentos da população idosa
39. Rubenstein LZ, Harker JO, Salvà A et al. Screening
brasileira: um estudo descritivo baseado na Pesquisa
for Undernutrition in Geriatric Practice: developing
Nacional por Amostra de Domicílios. Cad. Saúde
the Short-Form Mini Nutritional Assessment (MNA-
Pública 2003;19(3): 735-43. https://doi.org/10.1590/
SF). J Gerontol A Biol Sci Med Sci 2001;56(6):M366-
S0102-311X2003000300006
72. https://doi.org/10.1093/ gerona/56.6.M366.
51. Veras RP. Garantir a saúde e o bem-estar dos
40. Lachs MS, Feinstein AR, Cooney Jr LM et al. A 19 of 20
idosos: desafios de hoje e amanhã. Rev. Bras.
simple procedure for general screening for functional
Geriatr. Gerontol 2015a;18(3): 473-74. https://doi.
disability in elderly patients. Ann Intern Med
org/10.1590/1809- 9823.2015.0146
1990;112(9):699-706. https://doi.org/10.7326/0003-
4819-112-9- 699 52. Guerra ACLC, Caldas CP. Dificuldades e
recompensas no processo de envelhecimento: a
41. Katz S, Ford AB, Moskowitz RW et al. Studies of
percepção do sujeito idoso. Ciênc. Saúde Colet
illness in the aged. The index of ADL: a standardized
2010;15(6):2931-2940. ID: lil-559825.
measure of biological and psychosocial function.
JAMA 1963;185:914-19. https://doi.org/10.1001/ 53. Caldas CP, Veras RP, Motta LB da. et al. Models
jama.1963.03060120024016. of Approach to Outpatient Older Persons Care.
Sci. J. Public Health 2014;2(5): 447-53. https://doi.
42. Moraes EN, Moraes FL, Lima SPP. Características
org/10.11648/j.sjph.20140205.21.
biológicas e psicológicas do envelhecimento. Rev.
Méd 2010;20(1):67-73. ID: lil-545248 54. Alves JED. Envelhecimento populacional no Brasil e
no mundo. Rev. Longeviver 2019;1:5-9.
43. Lawton MP, Brody EM. Assessment of people:
self-maintaining and instrumental activities of daily 55. Lourenço RA, Veras RP. Mini-Exame do Estado
living. Gerontologist 1969;9(3):179-186. http://dx.doi. Mental: características psicométricas em idosos
org/10.1093/geront/9.3_Part_1.179 ambulatoriais. Rev Saúde Pública 2006;40(4):712-19.
https://doi.org/10.1590/S0034-89102006000500023
44. Tinetti ME. Performance-oriented assessment
of mobility problems in elderly patients. J. 56. Moraes EN de, Lopes PRR. Manual de Avaliação
Am. Geriatr. Soc 1986;34:119-126. https://doi. Multidimensional da Pessoa Idosa para a Atenção
org/10.1111/j.1532-5415.1986.tb05480.x Primária à Saúde: Aplicações do IVCF-20 e do
ICOPE. 1ª Edição, CONASS, 2023. 95p.
45. Abicalaffe CL. Pay For Performance Program for
Brazilian Private Health Plan. How to Implement and 57. Paixão Júnior CM, Reichenheim ME. Uma revisão
Measure. In: ISPOR, 13., 2008, Toronto. Anais […]: sobre instrumentos de avaliação do estado funcional
Toronto: ISPOR, p. 1-10, 2008. do idoso. Cad. Saúde Pública 2005;21(1):7-19. https://
doi.org/10.1590/S0102-311X2005000100002
46. Costa ALFA, Santos VR. Da visão à cidadania:
tipos de tabelas de avaliação funcional da leitura 58. Veras RP. Coordination of care: a contemporary care
na educação especial. Rev. Bras. Oftalmol model for the older age group. MOJ Gerontol. Geriatr
2018;77(5): 269-302. https://doi.org/10.5935/0034- 2020a;5(2):50-53. https://doi.org/10.1590/S0102-
7280.20180065 311X2005000100002
47. Nitrini R, Scaff M. Testes neuropsicológicos de 59. Oliveira M. Cordeiro, H.; Veras RP. O modelo de
aplicação simples para o diagnóstico de demência. remuneração definindo a forma de cuidar: por que
Arq. Neuropsiquiatr 1994;52(4):1-10. https://doi. premiar a ineficiência no cuidado ao idoso? J. Bras.
org/10.1590/S0004-282X1994000400001 Econ. Saúde 2018;10: 198-202. ID: biblio-915120
48. Yesavage JA, Brink TL, Rose TL et al. Development 60. Veras RP. Experiências e tendências internacionais de
and validation of a geriatric depression screening modelos de cuidado para com o idoso. Ciênc. Saúde
scale: a preliminary report. J. Psychiatr. Res. Colet 2012;17(1): 231-37. https://doi.org/10.1590/
1992;17(1):37-49. https://doi.org/10.1016/0022- S1413-81232012000100025
3956(82)90033-4
61. Ramos LR, Tavares NUL, Bertoldi AD et al.
49. Nunes BP, Soares UM, Wachs LS et al. Hospitalização Polifarmácia e polimorbidade em idosos no Brasil:
em idosos: associação com multimorbidade, um desafio em saúde pública. Rev. Saúde Pública
atenção básica e plano de saúde. Rev. Saúde 2016;50(suppl 2):1-10. https://doi.org/10.1590/S1518-
Pública 2017;51(43). https://doi.org/10.1590/S1518- 8787.2016050006145
8787.2017051006646

Rev. Bras. Geriatr. Gerontol. 2023;26:e230233

Contemporary care model for the elderly: the current need

62. Maia LC, Colares TFB, Moraes EM de et al. Idosos 69. Veras RP, Oliveira M. Envelhecer no Brasil: a
robustos na atenção primária: fatores associados ao construção de um modelo de cuidado. Ciênc.
envelhecimento bem-sucedido. Rev. Saúde Pública Saúde Colet 2018;23(6): 1929-1936. https://doi.
2020;54:1-10. https://doi.org/10.11606/s1518- org/10.1590/1413-81232018236.04722018
8787.2020054001735
70. Veras RP, Galdino AL. Caring Senior Modelo
63. Cachioni M. Universidades da terceira idade: das Assistencial Contemporâneo: Coordenação de
origens à experiência brasileira. In: Neri AL, Debert cuidado, ampliação da qualidade e redução de custos.
GG(org). Velhice e Sociedade. Campinas: Papirus, Rio de Janeiro: UnATI/UERJ, 2021.
1999, p 141-178. ISBN-13:978-8530805579. 20 of 20
71. Silva AMM, Mambrini JVM, Peixoto SV et al.
64. Ramos LR, Andreoni S, Coelho-Filho JM et al. Uso de serviços de saúde por idosos brasileiros
Perguntas mínimas para rastrear dependência em com e sem limitação funcional. Rev. Saúde Pública
atividades da vida diária em idosos. Rev. Saúde 2017;51(suppl1):1-10. https://doi.org/10.1590/S1518-
Pública 2013;47(3):506-13. https://doi.org/10.1590/ 8787.2017051000243
S0034-8910.2013047004325
72. Baltes PB, Mayer KU, Helmchen H et al. “The Berlin
65. D’orsi E, Xavier AJ, Ramos LR. Trabalho, suporte Aging Study (BASE): Overview and Design”. Ageing
social e lazer protegem idosos da perda funcional: Soc 1993;13(4): 483-515. https://doi. org/10.1017/
estudo epidoso. Rev. Saúde Pública 2011;45(4):1-10. S0144686X00001343.
https://doi.org/10.1590/S0034-89102011000400007
73. Giacomin KC, Peixoto SV, Uchoa E et al. Estudo
66. David HMSL, Riera JRM, Mallebrera AH et al. A de base populacional dos fatores associados à
enfermeira gestora de casos na Espanha: enfrentando incapacidade funcional entre idosos na Região
o desafio da cronicidade por meio de uma prática Metropolitana de Belo Horizonte, Minas Gerais,
integral. Ciênc. Saúde Colet 2020;25(1):1-10. https:// Brasil. Cad. Saúde Pública 2008;24(6):1-10. https://
doi.org/10.1590/1413-81232020251.29272019 doi.org/10.1590/S0102-311X2008000600007
67. Veras RP, Caldas CP, Cordeiro HA. Modelos de 74. Oliveira M, Veras RP, Cordeiro HA. Supplementary
atenção à saúde do idoso: repensando o sentido da Health and aging after 19 years of regulation: where are
prevenção. Physis 2013;23(4): 1189-1213. https://doi. we now? Rev. Bras. Geriatr. Gerontol 2017;20(5):624-33.
org/10.1590/1413-81232020251.29272019 https://doi.org/10.1590/S0102-311X2008000600007
68. Moura, MMD; Veras RP. Acompanhamento do 75. Aguiar CF, Assis M. Perfil de mulheres idosas
envelhecimento humano em centro de convivência. segundo a ocorrência de quedas: estudo de demanda
Physis 2017;27(1):19-39. https://doi.org/10.1590/ no Núcleo de Atenção ao Idoso da UnATI/UERJ.
S0103-73312017000100002 Rev. Bras. Geriatr. Gerontol 2009;12(3):1-14. https://
doi.org/10.1590/1809-9823.2009.00007.

Rev. Bras. Geriatr. Gerontol. 2023;26:e230233