By Peter Lloyd-Sherlock, Karla Cristina Giacomin, and Lucas Sempé
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By 2020, there were 290 million people aged 70 or older living in developing nations. As the older population grows in richer countries as well, calls are arising for new models of health and social care to support independent living at home and limit unnecessary hospital admissions. In countries such as the United Kingdom and the United States, belatedly merging services developed independently over decades has proved very challenging. In this short article, we look at a novel program operating in Brazil.
Even before the COVID-19 pandemic hit Brazil, there were concerns about the effects of population aging on health services, especially hospital care. Between 2000 and 2013, 31 percent of inpatient spending on people aged 60 years or older (amounting to $275 million in U.S. dollars in 2013) was for conditions better suited to ambulatory treatment (Souza and Peixoto, 2017). The leading causes of admissions were urinary tract infections, falls, and poor management of chronic conditions — all of which are often avertable through effective home and outpatient care.
Wondering if the solution could be to integrate health and social care in the community, some local governments began to experiment. For example, in 2011 the city of Belo Horizonte set up Programa Maior Cuidado (PMC — Older Person’s Care Programme), a program to support dependent older people in disadvantaged communities. PMC offers families support from trained caregivers who are recruited from similar communities and paid a basic wage. Each family gets between 10 and 40 hours of support a week, depending on the level of need of the individual and the family. PMC caregivers have uniforms and are jointly supervised by staff from the local health and social assistance centers.
Rather than replace family responsibility, PMC caregivers provide empowering support in a number of ways. They offer relatives some respite from what often is an exhausting 24/7 responsibility and also work with families to build their care skills and competence. Together with the older person, the PMC caregiver and relatives agree on a care plan, which receives a monthly review in joint meetings of health professionals and social workers.
Thus, given the program’s promise, we decided to take a look at it more closely.
Evaluation Reveals a Promising Program
Since 2018, we have been running an evaluation of PMC. The work is ongoing and inevitably has been hampered by the COVID-19 pandemic. Our findings to date show PMC often helps to:
• manage health service use by older people;
• improve the care they get at home;
• relieve the pressures of daily caring felt by relatives (who are almost always women); and
• offer new skills and employment opportunities to local residents who become trained PMC caregivers.
This is an impressive array of positive effects —effects supported by evidence, including statistical comparisons of older people in PMC and people of similar age, gender, and socio-economic profiles. PMC is associated with fewer unplanned health visits and more frequent use of health promotion services such as rehabilitation (Lloyd-Sherlock, Giacomin and Sempé, forthcoming). Interviews and discussions with people involved in PMC’s day-to-day operation and with beneficiary families show how it can prevent acute health episodes, limiting the need for emergency hospital admission. For example, the daughter of a 92-year-old man with multiple chronic health conditions hospitalized on several occasions for failing to manage them told us:
The PMC carer sets up his oxygen supply and stays with him chatting about this and that… She’s always on the look-out in case there is anything different about him. She notices little things and then she’ll tell me, "Look, there must be something going on with him. I’ll have word with the people at the health centre."
Although the main goal of PMC is to improve the care older people receive from their families, it recognizes accomplishing that goal requires social workers and health professionals to work together to understand families’ wider circumstances. In the poor communities where PMC operates, people of all ages face multiple problems, including addiction, unemployment, violence, and mental trauma. Acknowledging those challenges, PMC offers family caregivers respite and support so they can live their own lives, as well as provide loved ones the help they need. As one nurse put it:
The daughter of one older woman told me that now that they are in PMC she has time
to wash her own clothes and do some things for herself. Before that, she didn’t have time for anything.
Over the years, PMC has also provided training and a fair wage to thousands of local residents—mostly, although not entirely, women. This has been central to its success. These PMC caregivers are the lifeblood of the intervention. Decent pay, training, and a professional identity enhance staff retention, accountability, and quality assurance. In this way, PMC has become an empowering career option for women in neighborhoods where steady employment is very limited.
Notwithstanding these positive effects, PMC is not without flaws. Working with disadvantaged families in poor and sometimes violent neighborhoods is never easy, and not all families are predisposed to cooperate. PMC cannot cater to the needs of older people living alone, who require other forms of support. As with almost all interventions involving different government agencies, communication and coordination are not always perfect. These dynamics sometimes lead to confusion and misunderstandings between health staff and social workers and a degree of institutional disconnect at higher managerial levels (de Souza Aredes et al, 2021).
Pandemic Presents Insights
While, as mentioned, COVID-19 presented challenges, our evaluation of PMC was largely complete by the start of the pandemic. Nonetheless, the pandemic presented a chance to see PMC from another angle. As the number of infections in Belo Horizonte rose, we wanted to see how PMC would cope. To protect PMC caregivers, it was necessary to replace most home visits with telephone calls. Over time, a hybrid system was put in place with video calls and home visits resuming when COVID-19 was less prevalent. In this way, it was able to provide at least some support to 85 percent of families. Frustratingly, PMC caregivers were not categorized by public health agencies as front-line health professionals and, therefore, were not prioritized for vaccination.
It is always dangerous to promote models of “best practice” to resolve complex issues. Integrating social care and health for older people is a common-sense step towards meeting the needs of older people and their families. It is, however, much easier to do in theory than in practice. By the start of the pandemic, several Brazilian cities were developing programs modeled on PMC, but their plans were postponed as they faced the immediate challenges of keeping health systems afloat. In fact, the need for approaches like PMC has been greater than ever during the pandemic, and not just in Brazil. As the new U.S. administration looks to transform support for family care, it might consider a fact-finding visit to this unheralded city in Brazil.
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References
J.de Souza Aredes, J.Billings, K.Giacomin, P.Lloyd-Sherlock and J.Oliveira Araújo Firmo (2021) Integrated care in the community: the case of the Programa Maior Cuidado (Older Adult Care Program) in Belo Horizonte-Minas Gerais, Brazil. International Journal of Integrated Care 21(2): 28, 1–12
Dias RD, Barros, JV. Burden of hospitalisation among older people in the Brazilian public health system: a big data analysis from 2009 to 2015. J Epidemiol Community Health 2019; 73(6):537-543.
Lloyd-Sherlock P, Giacomin KC and Sempé L. The effects of an innovative integrated care intervention in Brazil on outpatient health service use by dependent older people. BMC Health Services Research (forthcoming).
Souza DK, Peixoto SV. Estudo descritivo da evolução dos gastos com internações hospitalares por condições sensíveis à atenção primária no Brasil, 2000-2013. Epidemiol e Serviços Saúde 2017;
The Kings Fund (2018). A year of integrated care systems: reviewing the journey so far, 2018. https://www.kingsfund.org.uk/publications/year-integrated-care-systems
WHO (2015) The World Health Organization report on ageing and health, WHO, Geneva.