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Integrating services for frail older people: the PRISMA Coordination Model Implementation and Impact in Québec, Canada Michel Raîche, MSc, PhD (c) Réjean.

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Presentation on theme: "Integrating services for frail older people: the PRISMA Coordination Model Implementation and Impact in Québec, Canada Michel Raîche, MSc, PhD (c) Réjean."— Presentation transcript:

1 Integrating services for frail older people: the PRISMA Coordination Model Implementation and Impact in Québec, Canada Michel Raîche, MSc, PhD (c) Réjean Hébert, and the PRISMA Group Research Centre on Aging, Université de Sherbrooke, Québec, Canada Programme of Research to Integrate the Services for the Maintenance of Autonomy

2 Content Introduction on Québec health system : context, problems, solution Description of the PRISMA model –6 components Implementation evaluation Evaluation of population impacts Lessons learned and recommendations

3 Geographical location * Sherbrooke

4 Demographic characteristics (Province of Québec) Tot pop. : 7.4 million >65yo: 0.9 million 30% disabilities and need for long-term services –at home –intermediate facilities –in LTC institutions (4%)

5 Québec social & health system Free, Universal, Accessible Social services AND Health : one Ministry Coverage –medical services (hospital & clinics) –nursing (home, hospital, LTC facilities) –medication Ministry of health: insurer, manager & services dispenser

6 CSSS (HSSC) Centres de santé et services sociaux Health and Social Services Centers 95 covering all the territory –rural areas –small cities ( ) –district of large cities Governed by a board (partially elected) Responsible for Primary care –prevention and health promotion –treatment –rehabilitation

7 CSSS Services Current services –medical –nursing –psychosocial services –Info-Health (telephone, 7/7, 24h/d) Programmes –Maternal/Child/Family/Youth –Mental health –Work health –Home services

8 CSSS Home services programme Standard Assessment –SMAF (Functional Autonomy Measurement System) 2 programmes –regular –intensive (>5 hours per week) Caregivers –CSSS's employees (mainly) –private agencies –direct allocation

9 CSSS: Home services Medical (coll. with private prac. Physicians) Nursing care Personal care & domestic assistance Psychosocial services Rehabilitation (physio, occ therapy) Nutrition

10 Other home support services Voluntary groups (ex.: Meals on wheels) Social Economy Enterprises (domestic) Temporary institutionalisation (respite) –planned –crisis

11 Institutions Admission mechanism –standard assessment (SMAF) –coordinated locally 3 types –Family-type residences (<10 residents) –Intermediate Facilities (10 +) –LTC facilities

12 Geriatric Services Out-patient Geriatric Clinic Assessment Unit Rehabilitative Unit Day Hospital Day Center Psychogeriatric services

13 Summary Geriatric Services Temporary Institutionalisation CSSS Home Care Voluntary Services General and specialised Hospitals Admission Coordination Definitive Institutionalisation Social Economy Enterprises


15 Problems Multiple entry points Services determined by the provider rather than the needs Multiple redundant assessments (different tools) Inappropriate utilization of costly resources Hospital-home transitions Delays for getting services Information sharing Partial response to the needs

16 Continuity of services Short-term (between services) –coordination and integration of services Long-term –adaptation of services to changing needs –longitudinality

17 Solution proposed: Integrated Service Delivery (ISD) Network

18 PRISMA Parntership University researchers + health managers + health ministry From research questions, to grant funding, implementation testing, and knowledge translation

19 Comparison of two models of Integrated Care Nested model (SIPA, PACE, CHOICE) Embedded model (PRISMA) Home Care Long-term Care Inst. Hospital & Rehab. Single entry Triage Case- Manager Home Care Hospital & Rehab. Long-term Care Inst. Case-Manager Multidisciplinary Team +/- Day Centre +/- Home care Entry

20 ISD Network 1.Coordination between services 2.Single point of entry 3.Case-management 4.Individualized Service Plan 5.Unique assessment tool (SMAF), Case-mix classification system (Iso-SMAF Profiles) and PRISMA-7 case-finding tool 6.Information tool (Computerised Clinical Chart)

21 1. Co-ordination between services Strategic (decision makers) –Local Governance Table: structures, financing and protocols Hospitals and CSSSs CEOs Chairs and directors of voluntary or private agencies –Shift of paradigm: client-centered  population-centered Tactical (services’ managers) –Local Management Committee: mechanisms Operational (clinicians) –Multidisciplinary team

22 2. Single point of entry Common door to get access to all services Triage (for people not refered by prof.) –Case-finding instrument: PRISMA-7 –reference to the right service or to the ISD Network –link to the 24/7 nursing phone line Basic data collection (socio-demographic)

23 ISD Clientele (admission criteria) To be over 65 To present moderate to severe disabilities –SMAF score  15 (out of 87) –Iso-SMAF profiles  4 To show good potential for staying at home To need for 2 or more services (health and social)

24 3. Case-Manager Functions –basic assessment (functional autonomy, needs) –reference to other professionnals (for completing the assessment) –planning of services (with patient & family) –service “broker” –patient advocacy –follow-up (periodic re-assessment)

25 3. Case-Manager Distributed by territory (neighbourhood) Nurse or Social worker or others Special training Not associated with a single institution or agency but with the Local Governance Table –intervenes wherever is the patient (“blue helmet”) May also provide direct care (in his/her field of competency) Case load: 40-45

26 Family physician Single point of entry Case-finding Case Manager Hospitals and Rehab. services Long-term care institutions Voluntary Agencies Social Economy Agencies CSSS Day Centre Institutionnalization (temp or permanent) Geriatric services Specialized and General Care Services Rehabilitation Home Care Nursing Care Occ. Therapy, etc. Domestic tasks Meals-on-wheels Specialized Physicians

27 4. Individualized Service Plan Prepared once the assessment is completed Lead by the Case-Manager Consensus amongst the providers Approval by patient (and/or family) –empowerment Includes the Management Plan of each provider Periodical revision

28 5. Unique assessment tool 1. SMAF: disability and handicap scale 2. Case-mix classification: Iso-SMAF Profiles –14 different homogeneous patterns of disabilities 3. Case-finding tool: PRISMA-7

29 5. Unique assessment tool: 1. SMAF SMAF (Functional Autonomy Measurement System) Hébert et al, 1988; item scale developed according to the WHO classification of disabilities SISTEMA DE MEDIDA DA AUTONOMIA FUNCIONAL By Karla Cristina Giacomin and coll. (Profs. Drs. Maria Fernanda Lima-Costa, Elizabeth Uchôa, Josélia Firmo et Sérgio Peixoto, Dr Réjean Hébert)

30 29 Incapacidades –5 dom í nios: 7 ADL: AVD 8 IADL: AIVD 6 Mobility: MOBILIDADE 3 Communication: COMUNICA Ç ÃO 5 Mental Function: FUN Ç ÕES COGNITIVAS Recursos –Materiais / sociais / arquiteturais –Estabilidade dos recursos Avalia 29 funções Handicap score 5. Unique assessment tool: 1. SMAF

31 Melhor informa ç ão dispon í vel Escala de 5 graus, indo de 0 a -3: 0 - faz sozinho/autônomo - 0,5 - faz com dificuldade -1 - necessita de supervisão ou estímulo -2 - necessita de ajuda, mas participa -3- necessita de ajuda total/dependência SMAF SISTEMA DE MEDIDA DA AUTONOMIA FUNCIONAL


33 SMAF translated in Portuguese Karla Cristina Giacomin Excellent results ( Coeficiente de correlação intra-classe) Thesis available at Epidemiologia da incapacidade funcional em idosos na comunidade: Inquérito de Saúde de Belo Horizonte e tradução e confiabilidade do instrumento de avaliação funcional SMAF no Projeto Bambuí Fundação Oswaldo Cruz Centro de Pesquisas René Rachou Programa de Pós-graduação em Ciências da Saúde Núcleo de Estudos em Saúde Pública e Envelhecimento Centro Colaborador da Secretaria de Vigilância em Saúde do Ministério da Saúde

34 5. Unique assessment tool : 2. Iso-SMAF Profiles Case-mix classification –Iso-SMAF Profiles 14 different homogeneous patterns of disabilities Generated from SMAF evaluation Functions: –Service allocation: admission criteria –Monitoring –Management: cost and resources by profile (budget equity)


36 Iso-SMAF Profiles of Long-term Home Care clients 0%20%40%60%80%100% Direct Allocation (n=1 723) Physical Deficiency (n=1 297) Intel. Deficiency (n=439) Disabled elderly (n=8 367) Profil 1 Profil 2 Profil 3 Profil 4 Profil 6 Profil 9 Profil 5 Profil 7 Profil 8 Profil 10 Profil 11 Profil 12 Profil 13 Profil 14 Motor Dis.ADLMental Dis.Very disabled

37 Distribution of ISO-SMAF profiles of a LTC facility profil 12 profil 13 profil 14 MotorIADLMentalMixed

38 5. Unique assessment tool : 3. PRISMA-7 PRISMA-7 validated to identify older people with SMAF score ≥ 15 Case-finding, not screening (related to future events) translated in Portuguese in Brazil: by Kylza Aquino Estrella et al.)

39 PRISMA-7 1. Você tem mais do que 85 anos de idade? 2. Sexo Masculino? 3. Em geral, você tem algum problema de saúde que exija que você limite suas atividades? 4. Você precisa de alguém para ajudá-lo regularmente? 5. Em geral, você tem algum problema de saúde que exija que você fique em casa? 6. Em caso de necessidade, você pode contar com alguém próximo a você? 7. Você regularmente usa muleta, andador ou cadeira de rodas?

40 6. Information Tool Facilitates information flow Computerized Clinical Chart –accessible by all professionals and institutions –via internet (Quebec Health and Social services Network) –security and privacy –data generator: for monitoring and research

41 The PRISMA Study : Implementation and Impact

42 Estrie project Funded by Implementation of the ISD Network within 3 areas –1 urban : Sherbrooke –2 rurals: Granit (Lac Mégantic) & Coaticook Evaluation –implementation (process): case-studies –impact (outcome): quasi-exp population design

43 Study territory 3 participating areas: Urban: Sherbrooke 144,000 (18,500 >65) Rurals: Coaticook (no hosp) 16,500 (2,300 >65) Lac-Mégantic (hosp) 22,000 (3,300 >65) Exp. Eastern Townships pop. : (40,000 >65)

44 Objectives for the implementation evaluation Monitor the degree of implementation between sub-regions; Get the opinion of policy makers, managers, clinicians, client and caregivers about the implementation; Assess the degree of integration; Analyse the work of the case-managers; Analyse the trajectory of care of clients; Evaluate the implementation of the CCC and the opinion of users and clients about its utilization; Analyse the ISP utilization; Identify the problems and difficulties in order to improve the system.

45 Degree of implementation Hébert et al. International J Integrated Care, 4, 2004 ( Indicators developed for each of the 6 components –Focus group with partners and researchers Relative weighting of the components For each component –determination of the indicators –weighting of the indicators Data collection –minutes of meeting (collaboration) –observation (single-entry, case-manager, C CC) –chart review (tool, ISP)

46 Implentation Rate in Sherbrooke 85,2%

47 Implementation Rate 85,2% 77,6% 69,3%

48 Conclusion for implementation PRISMA Model can be implemented Implementation rates reached 70 to 85% Perception of degree of integration by managers and clinicians was good to very good (communication/cooperation level)

49 The PRISMA Impact Study

50 L’Islet Lévis Montmagny Granit Sherbrooke Coaticook Experimental Zone Comparison Zone Impact study

51 Summary Flow of the Study T           T-3T-2 T T-0 Implantation du RISPA Total of 2 cohorts : 920 (2001) (2003) = 1501 (728-X, 773-T) End: Mid-march 2006 T-2-BT-3-BT-4-B Sherbrooke Coaticook Granit Lévis L’Islet Montmagny ==================== ===== TOTAL: Ces données sont basées sur le nombre de sujets évalués à domicile

52 Functional Decline Loss of 5 points + SMAF Death Institutionnalised p=0, % dif. p=0.030 p=0.685 Evolution of subjects exposed to PRISMA (excluding death and institutionalized)

53 New Cases of Functional Decline (Incidence) p < 0,001 14% dif. p<0.001 p=0,050 p=0.259 p=0.316 p=0,057 p=0.568 Loss of 5 pts + on SMAF Death Institutionnalisation

54 Experimental Comparison p=0.026p=0.054 p=0.203 p<0.001 Handicap (SMAF): Proportion with at least one unmet need ↓31%

55 Global Satisfaction p<0,001 p=0,107 ↑ of 5% p<0,001 Improvement of satisfaction p=0,003 p=0,026 p=0,226 p=0,925 p=0,106 p=0,002 p<0,001 p<0,001 p<0.001 p<0,001 XCXC

56 Satisfaction with services Delivery Organization p<0.001 XCXC

57 Empowerment p<0,001 XCXC Improvement of Empowerment p=0,727 p=0,200 p=0,170 p=0,703 p=0,190 p=0,003 p=0,001 p<0,001 p=0,001 p=0,347

58 Services Utilization Emergency visits Hospitalizations Home Services for older people (Day Hospital & Centre, home care and services) Clinicians consultation (general practitioners, specialist, nurses and others) Voluntary services (meals-on-wheels, community meals, transportation, etc.)

59 At least one visit to ER p< 0,001 p=0,355 p<0,001 Probability of at least one visit p<0,001 p<0,001 p=0,149 p=0,232 XCXC

60 At least one hospitalisation p=0,113 p=0,707 p=0,027 Probability of being admitted at least once p=0,204 p=0,364 p=0,953 p=0.449 XCXC

61 Other services No significant differences on: –Re-hospitalization –Consultations with health prof. –Utilization of home care services –Utilization of geriatric services

62 Total cost XCXC p<0,001 Comparison: p=0,343 Public and private parts * p<0,10 ** p<0,05 *** p<0,01

63 Total Cost Public part Private part p<0,001 Comparison: p=0,541 p<0,001 Comparison: p=0,494 XCXC * p<0,10 ** p<0,05 *** p<0,01 **

64 Conclusion for the impact Significant effect on: –Functional Decline: prevalence (6%) and Incidence (14%) –Handicap (Unmet needs): ↓ by half –Satisfaction and empowerment –ER –Hospitalisation (nearly significant) No effect on: –Institutionalization –Consultations with health prof –Home care services Equal Cost: improves the efficiency

65 Higher Equal Inferior less efficient less efficient to evaluate less efficient equally efficientmore efficient not efficient more efficient LowerEqualHigher COSTCOST EFFECT Efficiency Table Experimental zone compared to control zone

66 More efficient : Decline Handicaps Satisfaction Emporwerment Equal efficiency: Mortality Autonomy Desire to institutionnalyse Less efficient : = COST LowerEqualHigher Efficiency results Experimental zone compared to control zone EFFECT

67 Efficiency Cost equals → implementation and functioning cost of ISD : compensated by economy on services, without reducing efficacy ISD produced positive effects on autonomy, satisfaction, empowerment…

68 Final word

69 2005 ~ end of study: Merge Hospital Health and Social Services Centre Home care (CLSC) Long term care (Institution) + +

70 Globally But : Administrative integration ≠ clinical integration Integration do not solve everything: –Lack of home care services –Accessibility But now we know that it would be worst without integration !

71 Lessons learned and recommendations Working with older people: obligated to coordinate our actions with other intervening parties: –Functional decline is multifactorial; multiple interventions from different sectors necessary vs health and autonomy problems Bring together the partners involved: a good step done today

72 Lessons learned and recommendations Consider time for coordination – most important Make agreement between partners, focus on what is good for older people Challenge: adapt the approach to local particularities – done in France Lack of coordination must now be considered as a risk factor for functional decline

73 Consult the web site at: Contact me:

74 Obrigado pela atenção e pela acolhida Research Team : Réjean Hébert, Michel Raîche Research : Danièle Blanchette, Suzanne Durand, Marie-France Dubois, Nicole Dubuc, Michel Tousignant, Gina Bravo, Johanne Desrosiers, André Tourigny, Lucie Bonin, Pierre Durand, N’Deye Rokhaya Gueye, Anne Veil, Nathalie-Audrey Joly, Myriam Bergeron, Maxime Gagnon, Marie-Claude Boissé, Valérie Guillot, Isabelle Labrecque, Dany Simard, Karine Veilleux, Annie Lévesque, Josée Mainville Partners : Céline Bureau, Johanne Bolduc, Robert Bellefleur, Pierre Richard, Mariette Bédard, Linda Dieleman, Lysette Trahan et William Murray

75 Supplementary slides

76 Epidemiologia da incapacidade funcional em idosos na comunidade: Inquérito de Saúde de Belo Horizonte e tradução e confiabilidade do instrumento de avaliação funcional SMAF no Projeto Bambuí Núcleo de Estudos em Saúde Pública e Envelhecimento Centro Colaborador da Secretaria de Vigilância em Saúde do Ministério da Saúde Karla C. Giacomin, MD, PhD Orientadora: Profª MªFernanda Lima-Costa, MD, PhD Co-orientadora: Profª Elizabeth Uchôa, MD, PhD Fundação Oswaldo Cruz Centro de Pesquisas René Rachou Programa de Pós-graduação em Ciências da Saúde

77 Coeficiente de correlação intra-classe para avaliação dos dois observadores de acordo com a capacidade funcional avaliada ¹ Refere-se às dimensões das capacidades funcionais testadas.

78 Coeficiente de correlação intra-classe para avaliação do mesmo avaliador, em dois momentos diferentes, de acordo com a capacidade funcional avaliada ¹ Refere-se às dimensões das capacidades funcionais testadas.


80 29 Elementos do SMAF AVD –Alimentar-se –Lavar-se –Vestir-se –Cuidar de sua pessoa (escovar os dentes, pentear-se, barba, unhas) –Fun ç ão vesical –Fun ç ão intestinal –Utilizar o toalete Mobilidade –Transferências –Locomover-se no interior –Instalar pr ó tese/ ó rtese –Deslocar-se em cadeira de rodas –Uso de escadas –Locomover-se no exterior Comunica ç ão –Visão –Audi ç ão –Fala Fun ç ões mentais –mem ó ria –orienta ç ão –compreensão –julgamento –comportamento AIVD –Cuidar da casa –Preparar as refei ç ões –Fazer compras –Lavar as roupas –Utilizar o telefone –Utilizar os meios de transporte –Tomar seus rem é dios –Gerir seu dinheiro

81 PRISMA is funded by : The Canadian Health Services Research Foundation and the following agencies :. Five Regional Health and Social Services Authorities (Estrie, Mauricie – Centre du Québec, Laval, Montérégie, Québec). Quebec Ministry of Health and Social Services. Quebec Health Research Foundation (FRSQ). Quebec Research Network on Aging. Sherbrooke Geriatric University Institute

82 Schedule of implementation Granit Coaticook Spring 2001 Spring 2002 Spring 2003 Spring 2004 Spring 2005 Sherbrooke Implementation Interim Report Formative Implementation Evaluation Final Report Summative Implementation Evaluation

83 Integration measure Human Services Integration Measure Browne et al, International J Integrated Care, 4, 2004 ( –Depth of integration for each sector 0= no awareness 1= awareness 2= communication (share information) 3= coordination or cooperation (modify to avoid duplication) 4= collaboration (jointly plan services) –Completed following focus groups by representatives of each sector involved

84 Mean Depth of Integration Unawareness Cooperation Communication Awareness Collaboration Coaticook: 2.4 ► Granit: 2.3 ▼ Perfect Excellent Very good Good Moderate Mild Little Very little Browne’s Indicators Sherbrooke: 2.5 ▲

85 Perceived integration

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