In France, for more than 20 years, the lengthening of life expectancy has been incredible, leading to the increase in illnesses generating mental disorders or neurological impairments affecting peoples’ self-sufficiency. The most common condition is Alzheimer’s disease (AD) : around 850,000 people in France are currently affected by AD, and 2 million French people may experience it in 2020. Hospitals, already often under strain, will not be able to cope alone with this influx of patients. It is therefore essential to find alternative and additional solutions.
It is this observation that prompted an experimentation to arise in 2004 in the Ile-de-France region with the support of the Regional Health Agency : the ambulatory Aloïs memory consultation, namely outside hospital.
The aim is to offer patients presenting with cognitive disorders an alternative to hospital, as a preventive strategy against dependency and anticipating any complications related to the disease, through the following five missions :
1. To coordinate an ambulatory memory consultation : neuropsychological assessment - diagnosis – inclusion within patient care - information/referral
2. To offer patients and their carers medical, psychological and social follow-up : workshops, support, advice and referral to medical and social establishments
3. To organise the inclusion of non-hospital-based patients in research cohorts and protocols concerning Alzheimer’s disease or similar diseases, and feed the National Alzheimer’s Database (BNA) with non-hospital data.
4. To develop a “memory teleconsultation” network in the “medical deserts” for persons with reduced mobility or located remotely (French around the world).
5. To train health professionals, particularly general practitioners, to identify cognitive disorders in practice and enable better referral, earlier diagnosis and more appropriate support.
This consultation is open to all people who complain about their memory or any other cognitive disorder, and whose MMS is more than 18. In particular : for young patients not treated in geriatric units, for a non-hospital-based population who would only attend a hospital consultation 10 years later as an emergency and to those living in medical deserts. Anybody can attend at the request of specialist doctors (neurologists, psychiatrists, geriatricians) or general practitioners. From 2004 to 2014, the entirety of this consultation was subsidised by public funds (ARS). Despite demonstrating a real social and economic benefit, public grants have been dramatically reduced. We have been forced to set up a social pricing grid and call upon private partners (mutual insurance, retirement funds, health insurance, etc) who now jointly finance this consultation. Aloïs services are not reimbursable by social security.
By dialling the dedicated telephone number 0810 091 013, people can reach the coordinator who will refer them to one of the 5 missions on offer.
More fluid and less stressful, particularly for young people and/or those wishing to remain in a non-hospital-based setting, this system offers access to a quick (< 3 months) and early (average MMS = 24 namely : mild stage) diagnosis . It is now well-established that an early diagnosis of the disease, with the setting-up of appropriate treatment for the patient and carer, has beneficial effects on all clinical, psychosocial , economic and environmental parameters. The direct consequences are reduced hospitalisations, delayed admission to retirement home (from 6 months to 1 year) , reduced complications (accidents on the road, at home, and general management), and defining legal protections which also lead to very beneficial effects for the health of the carer. Early diagnosis also offers the patient the possibility, which is essential, to define his/her own life choices at a time when he/she is still capable of making decisions. Thus, in France, the MMSE score at the time of dementia diagnosis is around 18/30, according to the PAQUID cohort and the BNA, namely that it is established in most cases at moderate stage, already corresponding to the second phase of outcome for the disease : it’s too late ! A non-hospital-based memory care facility and the management of patients and carers by a nearby network can help to resolve this problem.
Integrated, coordinated and computerised, this ambulatory memory care facility acts in addition to the existing one, by positioning itself where the demand is genuine. Moreover, it participates in the national research effort by referring patients at a mild stage towards hospital research protocols.
This entire system, which constitutes a true social advance, has helped to support more than 7000 patients (registered on the National Alzheimer’s Database) and 3000 carers in the Ile de France region since its creation. The impact has been extensive : a study has just estimated the savings made at close to 200 million euros per year, including 135 million for sickness insurance, if all patients were diagnosed via this type of care facility. If the wholly ambulatory aspect is not desired, these figures still indicate a drive to organise better distribution of patients between hospital and ambulatory settings.
The purpose of this system is therefore to offer a quick diagnosis, at a convenient time, at a nearby location that is less traumatic for the patient and less costly for society. It functions in addition to hospital care facilities by absorbing the simple memory complaints and thereby contributing to relieving the congestion in hospitals, particularly in the Ile de France region, for the benefit of complex or atypical cases. It enables optimised referral of the patient towards more suitable establishments depending on their profile.
This system also provides an answer to the problem of “medical deserts”, via the remote consultation : the “memory teleconsultation”. It has been at experimental stage for the past year between Paris, the Ardèche and the Haute-Loire regions and soon to be launched with the French of Algeria. At the same time, Aloïs has just launched an original study in partnership with the Avicenne university hospital, the KappaSanté company and with the support of the KLESIA group, which mainly aims to validate the procedure for passing tests in consultation (neuropsychologist face to face with the patient) versus teleconsultation (neuropsychologist on the screen).
Preventing, anticipating, innovating, supporting, developing telemedicine, overcoming medical deserts and developing the ambulatory approach are currently public health priorities (cf. Law on Health and Law on adaptation of society to ageing). Many objectives are fulfilled by this memory care facility, of which a number of participants from the private and public sector have already considered that adopting it on a national scale within a context of social urgency and public finance crisis makes complete sense. In October 2013, Aloïs was approached by ASHOKA (leading international network of assistance to innovative social entrepreneurs - http://france.ashoka.org) because of is social dimension and relevant action on health and public finances. It also received the Grand Prix des Bonnes Nouvelles du Territoire in partnership with CNAM in December 2013.
This original model for a memory care facility should now progress from this experimentation stage and find the means of being nurtured for it to be integrated into a common right.
The government circular (October 2011) defining the specifications of memory care facilities does not mention this type of ambulatory care facility. It would seem that this omission is now an administrative delay to continuing regional public financing which it benefited from until then. Other partners and financiers have already been identified to enable the Aloïs network to continue the work achieved, to develop further and to replicate itself across the whole territory. This new initiative has proved its worth, and we now wish for it to be integrated into the common right in specific terms. The healthcare system will breathe new life as a consequence for the greatest benefit of all.