• Integrated Care

    Background    

    Many government-subsidized services are available to older adults in Israel. These services include community-based health care, hospitalization, home nursing care, welfare, social services, housing, disability and long-term care grants. However, there is little coordination between government agencies and medical health facilities and clients are expected to navigate this system on their own. The lack of communication between service providers does not allow for the customization of services for an individual's needs.  

    This absence of effective communication and overarching supervision leads to older adults not receiving the services they need. This is especially true for individuals who live on their own, have no family support, have multiple medical problems, and/or have low economic status. Thus, Israel’s older adults are not gaining the full benefit of what the country can offer and the country is not efficiently maximizing its available resources.

    It is estimated that of Israel's approximately 900,000+ older adults, there are approximately 40,000 facing complex life circumstances - multiple chronic illnesses, lack of familial support, poverty, complex health and social challenges – who are not receiving the full benefit of available services and are falling through the cracks.

    Need

    There is need for a comprehensive client-focused care system that provides customizable services for vulnerable older adults to ensure that they optimize services and rights available to them and continue to live with dignity within the community.

    Program

    Eshel's integrated care program addresses the diverse and complex needs of Israel's most vulnerable older adults through a case management approach. This enables clients to better navigate the fragmented service system by having an individualized care plan centered on themselves and their families. Additionally, the program enables the more efficient utilization of resources to help older adults maintain stable levels of function and health.

    A case management team comprised of a nurse and social worker take joint responsibility of the client - assessing the client's needs and providing a tailed solution. The case management team works with each client for approximately six months to ensure that all solutions remain in place and that community services or client's family members are monitoring the older adult's care.

    The program is being piloted in three locations in Israel: Jerusalem (a major city), Ashkelon (a small city in southern Israel), and Netivot/Sdot Negev (a regional council in southern Israel), with a caseload of approximately 1,000 clients.

    In 2018, a forth pilot location will be launched in northern Israel, as well as a pre-pilot program of integrated care for older adults living with disabilities.

    Outcomes

    • Transparent and seamless continuum of services
    • Cooperation between various system bodies
    • Efficient recovery through development and implementation of treatment plan
    • Live independently at home with dignity
    • Maintain physical and cognitive abilities
    • Feel secure due to the presence of a support network 
    • Utilize rights and services effectively in accordance with preferences and needs

    Contract dates

    2016 - 2019

    Partners

    National Insurance Institute, Ministry of Welfare, Ministry of Health, HMOs