Program of Research to Integrate the Services for the Maintenance of Autonomy

Key Implications for Decision Makers

The work of the Program of Research to Integrate the Services for the Maintenance of Autonomy (PRISMA) began in 1999 to answer the question in the current socio-health context and in light of the existing resources and structures, can the implementation of mechanisms and tools to deliver integrated, continuous services enhance the relevance (response to needs), quality, effectiveness and efficiency of care and services for people with diminished independence? After five years of work, we can answer "yes" to this question. The co-ordination type of integration model developed by PRISMA can be implemented in Quebec's socio-health context. Integration of services for elderly people helps maintain their independence without increasing costs to the healthcare system. It prevents loss of independence and makes wiser use of services, especially hospital emergency services. This experience shows that establishment of an integrated services network is based primarily on participation by qualified, credible and dedicated people who show the realism and relevance of the new service co-ordination system. This requires the support of heads of organizations involved in the co-ordination model selected. They must view establishment of this network as an appropriate solution for the service organization problems they deem a priority. The managers and workers affected by the change will need time to forge co-operative links and take ownership of the co-ordination model selected.

The tools developed by PRISMA effectively support integration of services by promoting client tracking, improving clinical assessment of individuals, facilitating development of an individualized service plan, assessing the quality of services, improving management of the network and facilitating information exchange.

Executive Summary

The Program of Research to Integrate the Services for the Maintenance of Autonomy (PRISMA) developed and tested an innovative model for organizing healthcare services that is designed to optimize the continuity of these services and adequately meet the needs of frail elderly clients. The findings show this model, implemented in the Eastern Townships of Quebec, helped maintain elderly people's independence, as well as led to better use of healthcare and social services, without increasing costs to the healthcare system.

PRISMA's work achieved the five objectives initially targeted:

  1. Make the mechanisms and tools required to deliver integrated services that foster continuity of care operational in strategic (governance), tactical (management) and operational (clinical) terms. The six components of the integrated network (concerted action, single service point, case management, individualized services plan, single assessment tool and computerized clinical file) implemented in three municipal regional counties in the Eastern Townships (Sherbrooke, Granit and Coaticook) were the subject of regular monitoring. At the end of our four-year study, the six components had been implemented 75 percent.
  2. Develop and validate clinical and management instruments to support making an integrated services system operational and facilitate adaptation to new modes of professional and organizational practices. These instruments refer to ISO-SMAF profiles and to the computerized clinical file. The findings of our work in the Eastern Townships and Montérégie confirm that ISO-SMAF profiles can be used to develop a budget allocation method for residential facilities as well as home support services. We also worked on validating the profiles for clients with a physical or intellectual disability. Given the findings of this study, it is possible to conclude that for most people with a physical or intellectual disability, the classification based on ISO-SMAF profiles could partly meet the need for the information required to offset their disability. We also strived to develop indicators of the services required in psychosocial interventions to complete the resources required and the costs associated with each profile. Based on a Delphi consultation of a group of experts, the following aspects were selected and indicators were generated: state of health, psychosocial status, status of caregivers, capacity for motivation and adaptation, communication and cognitive functions. Given the sharp rise in private residential facilities and the lack of data on the needs of these clients, a first incursion by ISO-SMAF profiles was conducted with private residential facilities. The findings confirm the presence of people with diminished independence in private residential facilities and reflect the heterogeneous nature of functional autonomy profiles in these settings. We also planned to refine the method for determining the nursing, assistance and support services required using the profiles. To this end, we conducted work that integrates two tools developed by researchers on our team: ISO-SMAF functional autonomy profiles and TEDDI, a software for conducting time-motion studies. For the computerized clinical file, the gerontological-geriatric information system version currently used in the Eastern Townships and Bois-Francs was upgraded with a data extractor and a report generator for use in management, as well as a tracking model that includes PRISMA-7.
  3. Develop, adapt and validate service quality measurements, a cost assessment method and service continuity indicators. For service quality, we proposed to experts a series of quality indicators. The indicators selected are related to effectiveness, safety, patient-focused care, continuity and access. These indicators will now be tested to assess their reliability and feasibility for assessment by quality indicators in the context of ambulatory care and services for elderly people in Quebec with cognitive or dementia problems. The cost assessment method developed by our team was applied as part of the PRISMA-Eastern Townships study. The findings on efficiency support the conclusion that the innovative integrated services network model for elderly people is no more costly than the traditional model, since the implementation and operating costs were offset by savings on services.
  4. Assess the implementation and operation of an integrated services system by specifically identifying the facilitating and restraining conditions in strategic, tactical and operational terms, from the perspective of people with disabilities and of their network of support, caregivers and managers. In light of our work, we can draw certain useful lessons for implementing current reforms in the healthcare and social services sector in Quebec. It should be noted that reinforcing the integration of services for the frail elderly is an innovation carried out locally. The success of this complex operation depends not only on the willing co-operation of local players, but also on structuring decisions made at the regional and central levels.
  5. Assess the impact of integrated networks on people with diminished independence, their support network, use of resources (public, private and volunteer) and the cost of services. We observed a seven-percent decline in loss of independence among elderly people participating in the PRISMA-Eastern Townships study. This group of elderly people posted a higher level of satisfaction with the healthcare system. These people also made more effective use of the services provided to them by the Centre local de services communautaires (CLSC) and thus were less reliant on emergency services. The level of independence was also higher among the people exposed to the integrated network. Finally, we note a levelling-off of hospitalizations among this sector of the population.