A single point of access to support for elderly people

Background in Monaco

Alongside every other country in Europe, the Principality of Monaco is facing an ageing population (a quarter of the nation’s population is over 60 years old) as well as the public health problem posed by Alzheimer’s disease and similar cognitive disorders. To best meet the needs of its elderly population and anticipate emerging requirements, in 2006 the Prince’s Government established the Monaco Gerontological Coordination Centre (CCGM).

Who is the single point of access for?

Anyone resident in the Principality aged 60 years or over, or their carer, can contact the Gerontological Coordination Centre for questions about:
● The future of a parent
● A friend
● A neighbour who is losing their independence
● Their own future
● Or if they are looking for information about the medical and social assistance available in the Principality

What kind of support does the Gerontological Coordination Centre offer?

Home help

The Gerontological Coordination Centre’s work focuses primarily on those suffering a loss of physical or cognitive autonomy. It involves identifying the applicant’s needs by carrying out a Standardised Gerontological Assessment in the person’s home. This assessment considers biological, psychological, social and environmental factors, leading to an individual identification of needs and a personalised support plan. The Standardised Gerontological Assessment will be reviewed on an annual basis, or at earlier stage if there is a loss of autonomy, and the support plan will be adapted as a result.

In the event of hospitalisation

There are two scenarios:
● In the case of individuals known to the Gerontological Coordination Centre, the team informs the social work team at the care facility. The latter sends the medical and social information required to develop a discharge support plan to ensure continuity of care until a new assessment can be carried out by the Gerontological Coordination Centre in the individual’s living environment.
● In the case of individuals who have not previously used the Gerontological Coordination Centre’s services, if the medical team in the hospital department notices a loss of autonomy and identifies a need for assistance on the individual’s return home, it sends a report, via the social work team, detailing the degree of autonomy loss (Independence, Gerontology, Iso-Resource Groups (AGGIR) grid). This enables an estimate to be made of the services required to cover the individual’s essential needs until the Gerontological Coordination Centre can carry out a full assessment of autonomy in the individual’s living environment, to meet the specific needs of each person.

What is a support plan for elderly and retired people?

A support plan is a set of recommendations. The individual and their family continue to take the decisions. The plan includes advice about health and the establishment of a support structure at home:
● Establishment of medical monitoring by a general practitioner
● Assistance from a healthcare professional
● Assistance from a carer, detailing the quota of hours, frequency of visits and tasks to be carried out
● Advice on home adaptation, from the provision of technical assistance through to making modifications to the home in partnership with the hospital’s Physical Medicine and Rehabilitation Service and the Department of Social Welfare and Social Services’ Disability Office
● Entitlement to benefits
● Participation in support groups

What are the benefits?

Admitting an individual to the Gerontological Coordination Centre monitoring process makes it possible to prevent crisis situations and to anticipate future needs and decisions, both medical and social. It improves responsiveness thanks to the links established between those providing assistance at home:
● The individual’s doctor
● Personal care services
● Healthcare professionals and specialist hospital partners, particularly from the hospital’s gerontological team (geriatric consultations, memory centre, cognitive behavioural unit, acute geriatrics units, long-stay units, retirement homes). In this way, a solid gerontological network is established, a kind of interdisciplinary system surrounding elderly people experiencing a loss of autonomy.

What care is offered by the elderly support team?

The Gerontological Coordination Centre’s medical and social work team comprises five separate teams (a geriatric doctor, a senior healthcare manager (coordinator), two nurses, three social workers and a secretary).

1. The geriatric doctor is responsible for conducting gerontological assessments of new applicants. These assessments are carried out in the individual’s living environment. The doctor validates the support plans and reassessments carried out annually by the nurses, and serves as a point of contact for the Centre’s medical, social work and administrative partners in sensitive and contentious situations.

2. The senior healthcare manager is responsible for managing, supporting and supervising the work of the team, as well as contributing to the development of support plans and validating them when the doctor is not available. The senior healthcare manager coordinates information and action with the Centre’s partners, is responsible for administrative management and operational analysis of the team, and is involved in training healthcare and social work staff.

3. The nurses are responsible for conducting annual reassessments of the individuals being monitored by the Centre. They evaluate the support plans put in place the previous year and highlight any difficulties encountered in the home. They contribute to the development and presentation of support plans, and organise coordination meetings focused primarily on health problems. They are in contact with those providing healthcare and social services in patients’ homes.

4. The social workers contribute to the development of support plans. They are responsible for carrying out social work assessments, setting up care and services in the home, and leading coordination meetings in the home. They help people to access their entitlement to benefits as required. One social worker focuses specifically on supporting patients when they are discharged from hospital.

5. The secretary takes calls made to the Gerontological Coordination Centre, gathers initial information and passes it onto the team so that the support process can begin. The secretary acts as a receptionist for public visitors to the Centre.