A model for integrated home care of frail older patients: The Silver Network project

Home care programs for the treatment of frail elderly have been developed i n many countries around the world. In the Silver Network project all servic es are provided in an integrated fashion by one "single entry" center, diff erently from the traditional fee-for-service or not integrated systems. The delivery of health and social services for frail elderly individuals are i ntegrated and coordinated by a case manager who uses a "second generation" assessment instrument, the Minimum Data Set for Home Care (MDS-HC). We desc ribe the principal clinical and functional characteristics of nearly 1300 p atients admitted between 1997 and 1998 to such an integrated home care prog ram in eleven Italian Health Agencies. The database, derived from the seria l MDS-HC assessments of each patient, provides a unique opportunity to deli neate the different criteria for eligibility for home care, and compare the selected populations of the participating Health Agencies. (C) 1999, Editr ice Kurtis.