In an effort to identify all the issues at stake in the home care sector and in order to offer increasingly specialised and optimal support, Telegrafik interviewed several specialists in the profession.
Mr. Homehr, you are the founder of a Territorial Professional Health Community south of Toulouse, in a rural and semi-urban area of 700 km2 covering 49 districts. Can you introduce yourself and describe this area, and in particular the health issues you encounter in your work?
Personally, I’m a country doctor. I’ve been in my own practice for 15 years. We have 4 partners and we work as a multi-professional health centre (MSP).
I proposed the creation of this TPHC in January 2019. We are located south of Toulouse, bounded by the motorway and the border with Gers to the West. We cover all the districts in a large rectangle, 49 in our case, including Muret (the largest district) and the Occitan Clinic, which is one of the reference establishments. We are able to enlist the help of the district’s health actors, mainly the private sector, with which we associate all the public and private structures, not forgetting the URPS and the ARS.
There is something very important about the CPTS: we’re talking about population issues.
In our case, the CPTS has a total 150,000 inhabitants, where there is access to emergency services and permanent care centres; we have the usual movements of patients, for which we must have an intelligent consultation. We’re talking about health organisations with a lot at stake; for example, in our region, 8.8% of patients do not have a general practitioner. So, one of our main missions, in conjunction with the ARS and the CPAM, which will help us to formulate diagnoses, will be to promote access to a doctor for the population.
Another “core” mission for us is unscheduled care, i.e. reducing the number of visits to emergency by patients who cannot find an available doctor within 48 hours. We are in an experimental group: the SAS 31 and our CPTS responded with the ARS to a call for projects from the ministry and we were awarded the prize for this experiment, as were 21 other French departments. To give you an idea of what is at stake, in Haute-Garonne we have 60,000 emergency visits per year which are nothing more than general medicine consultations; and on the other hand, we have 70,000 consultations to which either a blood test or an X-ray is added, which we do in our practices. It’s still general medicine. You can imagine, that’s 130,000 emergency visits per year that maybe could be transferred to our medical practices, provided we get organised.
Les CPTS ont pour mission de trouver des organisations internes pour retenir sur le territoire ces personnes qui par anxiété, ou peut-être par manque de visibilité d’un planning de médecin, vont se rendre aux urgences, alors qu’un médecin pourrait être disponible quelque part pour résoudre le problème par une consultation ou téléconsultation.
The CPTSs have the task of finding internal organisations to keep in the district those people who, out of anxiety or perhaps because of lack of visibility of a doctor’s schedule, go to the emergency department when a doctor could be available somewhere to solve the problem by a consultation or remote consultation.
In total, our CPTS currently has 20 missions, ranging from geriatrics to paediatrics, including psychiatry, as well as digital health and Artificial Intelligence. In addition, we also act as partners within clinical studies, such as treatment for Covid-19, and with various associations or stakeholders, such as associations that deal with caregiver burnout.
It is up to us to be innovative in this coordinated care, to dream up things that will meet the needs of all these people.
Among all these groups, your CPTS is called upon to meet the health needs of many elderlies and/or frail people: why do you think it important to develop outpatient care, especially with a view to maintenance or return home rather than to a hospital or specialised establishment?
There are three phases of life: robustness, i.e. people like you and me, who are completely independent, either cognitively or physically; then there is frailty, during which we start to have minor problems in carrying out actions and thinking about certain subjects; and finally we arrive at dependence.
The challenge is to say that if we detect these patients who are fragile, we can return them to robustness for perhaps a few months, or a year, or even three years. These are major public health issues, as patients who enter frailty would also fall into dependence much more quickly. This subject is also being developed with the WHO, under the powerful initiative of Professor Vellas who is one of France’s leading experts on frailty and geriatrics, and has collaborated at global level to create an application for identifying frailty, based on clinical criteria and known as ” ICOPE”.
We have become the first CPTS to deploy ICOPE in France, with 18 months of collaborative work with the teaching hospital, both away from hospitals and in vaccination centres, and now in institutions: we, the liberal field actors, are coming to train clinics and their nurses, managers and doctors to carry out screening.
The parallel with the Telegrafik solutions is that we are looking at ways, this time in conjunction with digital technology, of keeping elderly people healthy. Not only the dependent ones but also those patients who are a bit fragile: being able to spot them at that moment. We need to be innovative with this large population, and as we already have expert teams of nurses as well as doctors, we have just appointed a coordinating nurse. We already have our CPTS coordinator who does part of the work, so we are in the process of strengthening all of this care and we also need to equip ourselves with tools and solutions such as those provided by Telegrafik, to optimise follow-up.
What are the issues, the key points behind this maintenance and monitoring at home, and how do you respond to them specifically within your CPTS? How are the services operated?
What role do you think technological innovations, and in particular digital tools, can play in meeting these new challenges?
When you are a GP, you are of course looking after patients at home. However, there are fewer and fewer of us doctors in proportion to the population, and fewer and fewer of us making visits as we are busy in our practices, and now the demand from the elderly has increased.
We find ourselves with a huge gap: we have many more patients to care for at home, a much larger patient base, and fewer and fewer doctors and steadily less doctor time available.
So, we have to find solutions.
We are currently working on this. I am chairing a ministerial commission of the General Supply and Care Directorate (DGOS), on derogations intended to strengthen the link between doctor and nurse, to give more possibilities for co-prescription by nurses, who will be more and more the arms, eyes and ears of the doctor in the home, while maintaining very close collaboration between doctor and nurse of course. Indeed, we need very careful monitoring of our patients: if we have been used to going to see a patient every month and now, we can only go every two months, we need human and technological support.
Technological innovations and especially digital tools provide a role in the anticipation and monitoring of symptoms, but not only that, and I don’t want to focus the discussion on the medical profession only, because the paradigm has changed. Traditionally, it’s always been the doctor who looks after the patient in a somewhat top-down way. Today, patients take care of themselves and have a number of health actors, who have become collaborators, around them. I insist on this term, the doctor becomes the patient’s collaborator. We have patients who are older in years, but younger in mind. A 75-year-old today is quite capable of handling lots of things, while 20 or 30 years ago a 75-year-old had much less in terms of physical and psychological resources. We have many patients who can be helped by their children, with digital tools in particular. So, we have a first sphere of surveillance, which can be self-monitoring or in the family or circle of friends, to which of course we add surveillance that will always remain medical.
In this case, we are now in predictive medicine, while over the past hundred years we have been in treatment medicine. Now we are able to prevent breast cancer, cervical cancer and colon cancer; there are large national organisations but we will be increasing these tenfold on a specific individual-dependent level.
For example, imagine a connected scale for someone with cardiac insufficiency; if in one week he gains 3 kg, we will deduce that he has accumulated 3 litres of water either in his legs or by left or right heart decompensation. We can imagine that tomorrow we will have tele-medicine systems, with warning systems on a sort of dashboard, which would report this weight gain for example.
This is one of the things that we will have to imagine putting in place; it already exists in chronic disease monitoring experiments, Etap for example: this could be cardiac insufficiency. Cardiac insufficiency accounts for 100,000 hospital admissions per year in France, even though in 80-90% of cases it can be prevented simply by measuring blood pressure and weight. Patients can be taught to do their own self-measurement, which could be sent by e-mail or otherwise.
This would avoid hospital stays, with complications such as hospital-borne diseases, falls or disruptions to care patterns, which would not occur with home care.
This has an impact on the patient’s quality of life: we will give the patient comfort with this very inclusive aspect.
As an EHPAD coordinating doctor, this is something I know very well. This morning I was doing an entry for a 92-year-old gentleman, who lived alone in his home, 6th floor with lift, and he had a stroke. His children were not exactly close by; it was getting complicated. He found himself institutionalised because of course he was afraid of walking and afraid of falling, and as soon as he came in, he said to me: “You know, Doctor, I was so happy at home! I’ve been living in retirement for 25 years, I had my little habits, I was comfortable at home. But I understand I have to…” He decided, he said to himself “I have to”. He’s got all his wits about him, he used to be a weather engineer.
So, you see all the time this fragility, which leads dependence, it’s a delight for patients to stay at home, in their habits, with their entourage, their pets, the little market.
This is our first victory as a medical profession: to say that we can keep our patients at home as long as possible.
Ten years ago, we didn’t have all this digital stuff, but we already had small iPads, work organisers and laptops that we could bring into the home and thus optimise monitoring. Today, however, we are increasingly accelerating and facilitating links with digital.
However, I don’t want to oversimplify things because digital is at the service of humans. We’re all happy that we can send each other text messages, but at the end of the text message we still have two humans. In health, it’s the same thing, we always have a patient, a nurse, a doctor, the physiotherapist, so we just adapt something, but we don’t replace medicine. We are optimising, the population is ageing, and we must allow it to age in good health. We must not wait for cancer to occur; we must detect it beforehand to treat it better.
There is always a human relationship and it will stay that way, even in the heyday of Artificial Intelligence, which can also provide great solutions in certain areas but will certainly not replace the added values of people and patients.
What is your vision of the future, and perhaps the vision you share with your colleagues when you discuss it together, concerning care of the elderly: patient typology, disorders observed, challenges to be met, improvements, objectives, legal frameworks, etc?
I’ll take an example: I’m a country doctor and at the same time I’m a specialist in digital medicine, digital health. I have a university degree, I work on a number of projects, I’ve become an expert in Artificial Intelligence, on which I support a number of projects.
As a country doctor, I sometimes do end-of-life care on farms, without the addition of all this digital stuff. As you can imagine I operate in white zones. But we can treat everyone just as well!
In fact, the aim is to adapt.
Maybe ten years ago, a certain part of the population started using these digital tools. Gradually the senior citizens’ clubs used tablets for example, to communicate with each other, which was very useful during the health crisis. They have been able to embrace all these tools, and health is no exception to these developments. Of course, there are fantasies and fears: we have to remember that tomorrow we won’t have robots with Artificial Intelligence that will be able to heal. I know this subject well and would like to reassure your readers on this point.
The addition of new technologies concerns a growing part of the population but is not for everyone, it can’t be done everywhere.
For example, we realised at the time of vaccination, with the organisation of vaccinations via the Internet, that we had more people from upper classes who were able to make these appointments more easily and more quickly. We also noted that in our rural areas, we had patients who tended to live in cities and travelled long distances to be vaccinated.
So, we’ve set up corollary systems to make it easier for the most vulnerable people, those most unable to use digital technology, to make appointments.
Of course, there are fewer and fewer cases of GPs working alone in their practices, on the verge of burnout.
I have been a university training supervisor for ten years. I receive interns and I give courses at the university. I never hear an intern say, “I want to go and live alone in the Ardèche”. It happens, but it’s very rare. All the younger generations, for several years now, have wanted to work in coordinated practice, health centres, shared care teams, and increasingly CPTS. And the CPTSs are even grouping together to optimise patient care, because in this way we can provide better treatment, and providing better treatment also means being with several people, because this makes us more intelligent, we go further and better.
Following the 2016 law, the CPTS had difficulty getting off the ground, and finally health professionals took to them and found these new modes of practice very pleasant, we come to them, it is optional, but we all join a project. It’s very rewarding. It’s also a hope.
We have seen over the last fifteen years this desire, this approach of grouping together our health professionals, to better take care of our users’ health.
The idea is to improve. For example, with computerisation everything is well organised, we have supports, and as soon as we need information we can immediately go and look for it on-line.
It’s obvious that today we provide better care, for longer period and for less money, and this is a variable that must be taken into account.
A number of health professionals, including myself, are very optimistic about these organisational methods and innovations, while continuing to do what we know best: touching, examining and palpating patients. Remote consultations can also be conducted more and more depending on the condition.
It is also important to look at what is being done around us, outside France and outside Europe, because in health, as we know, many experiments are conducted in the United States and gradually shape the European and then the French landscape.
Whether you are an infant or pregnant or have a disease or a psychiatric or locomotor disability, if you’re elderly or even if you’re healthy and want to stay that way, it’s now much easier to be cared for, to be taken care of a little bit everywhere, despite what we hear.
I have helped departments that have deteriorated in terms of general practice, and have shown innovation, much earlier than other departments with many more doctors. And these innovations are hospitals, specialists and general practitioners but also pharmacists or nurses, who have set up innovative organisation methods between them to make up for this lack of general practitioner. This has now been going on for several years, and the feedback from patients is rather good, they are happy to be looked after in a different way.
So, the march is on! We are not going to stop it, and the trend is going to get stronger: grouping together, working more closely, cooperation between professionals and with patients. One might call it therapeutic education, i.e. teaching patients to know their conditions and to take better care of them in terms of prevention but also of treatment.
These are modern methods, developed over the last fifteen years, and it is thanks to these multi-professional organisations that we can the time to carry out all this therapeutic education and teaching of patients. And of course, we work with several doctors and also with other professions, because care of patients is not limited to a general practitioner and a specialist doctor, we are really on a multi-professional team logic.
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