PRISMA: Developing integrated services delivery for functional autonomy
Réjean Hébert, MD, MPhil, Université de Sherbrooke
André Tourigny, MD, MBA, Université Laval
Michel Tousignant, Pht, PhD, Université de Sherbrooke
Louis Demers, PhD, École nationale d'administration publique
Nicole Dubuc, RN, PhD, Université de Sherbrooke
Diane Morin, RN, PhD, Université Laval
Danièle Blanchette, PhD, CA, Université de Sherbrooke
Lucie Bonin, Agence régionale de santé et de services sociaux de Mauricie-Centre-du-Québec
Yves Couturier, Université de Sherbrooke
The PRISMA project is a collaborative research partnership designed to develop and implement mechanisms and tools to enable integrated services delivery for frail older people. Involving researchers, policy makers, managers, and clinical practitioners, the PRISMA group has developed a model that includes coordination mechanisms at the governance, management, and clinical levels; a single-entry point for access to services; case management; individualized service plans; a unique assessment tool; and a computerized clinical chart. The PRISMA model has been successfully implemented in multiple regions and has significantly influenced the development of policy and programs for the frail elderly in Quebec.
Traditional hospital-centred care is inappropriate for many chronic illnesses that require ongoing, long-term care. For these kinds of illnesses, which affect many elderly people, a different model of care, one that centres on the users' place of residence, may be more appropriate. Such a model calls for major changes in the organization and delivery of health and social services, with a primary focus on front line health and home care. Given the plethora of organizations and professionals involved, integrated services are crucial.
The PRISMA project aims to develop, implement, and evaluate mechanisms and tools to improve the continuity of care and integrate health services for frail older people in Canada. The PRISMA model of Integrated Service Delivery (ISD)1 includes all public, private, or volunteer organizations that provide care and services to frail elders, and consists of six components: coordination mechanisms at the governance, management and clinical levels; a single-entry point for access to all services; case management; an individualized service plan; a unique assessment tool with a case-mix classification management system; and a computerized clinical chart.
The PRISMA group is led by Dr. Réjean Hébert from the Université de Sherbrooke's Research Centre on Aging and includes 15 researchers from both this centre and the Université Laval geriatric research team. These two research teams work with the directors and managers of the health and social services network from the Ministère de la Santé et des Services sociaux (MSSS), the Institut national de santé publique du Québec, five Regional Health and Social Services Boards (RRSSSs), and the Sherbrooke Geriatric University Institute (a hospital centre and long-term care facility). PRISMA represents a unique partnership of researchers, policy makers, managers and clinical practitioners, who collaborate to define research objectives, design and carry out protocols and introduce results back into the field through innovative services and programs.
The KT initiative
The PRISMA group develops, implements, and evaluates ISD mechanisms and tools primarily by studying frail older people experiencing loss of autonomy. In the late 1990s, an initial project in the Bois-Francs area of Quebec, which was led by the area's RRSSS, requested support from researchers at an early stage to evaluate the experiment and contribute to the development and piloting of project mechanisms and tools. A close collaborative relationship was created between researchers, policy makers, health managers, and clinicians, leading to the later development of the PRISMA model and its components.
In each region, PRISMA teams meet more regularly to design and implement experiments, monitor and analyse the results, and discuss translation strategies.
The evaluation of this initial pilot project provided useful information to decision makers, managers and clinical practitioners for current and future implementations. A second initiative to implement an ISD, in the Estrie region, involved the same pattern of collaborative work in designing, implementing, and analysing the experiment, and transferring the results. Other RRSSSs became interested in some components of the model and also joined the PRISMA group.
The provincial PRISMA group includes representatives from the research team, the MSSS, and the participant RRSSSs. It meets three times a year to overview the work of the group; exchange knowledge on current issues, problems, and results; determine future projects; and plan knowledge translation (KT) activities. In each region, PRISMA teams meet more regularly to design and implement experiments, monitor and analyse the results, and discuss translation strategies. A continuous exchange process is in place to monitor change and respond to emerging needs.
We also conduct many activities to disseminate PRISMA's results. We have held three colloquia, reaching over 600 clinicians, managers and policy makers in Quebec, and have also visited facilities wishing to implement some of our tools. A regularly updated website provides information about PRISMA's work, and a book summarizing PRISMA's work to date was recently published in both French2 and English.3
Results of the KT experience
PRISMA has developed and implemented many tools to support integrated services delivery and to facilitate a shift to new professional practices and organizational change. During the Estrie implementation, for example, case managers and clinical practitioners requested a simple screening tool to identify frail elders who might eventually enter the ISD system. The research team designed and validated the PRISMA-7 questionnaire,4 which is now used on a telephone health line, by voluntary agencies and in clinical settings to identify older people who should be referred to case managers and more completely assessed.
During the Bois-Franc initiative, we recognized that it was vitally important to have a computerized clinical chart that facilitated communication between health care workers and organizations. This information system, the Système d'information géronto-gériatrique (SIGG), is a computerized version of the unique assessment tool and includes the Système de mesure de l'autonomie fonctionnele (SMAF) disability scale. The SIGG uses an existing secure health and social services communication network (RTSS) in Quebec and is accessible by professionals in all institutions via the Internet to share information about clients.
We have also developed a case-mix classification system based on the SMAF scale—Iso-SMAF profiles—for accountability and performance evaluation. These profiles classify patients according to functional autonomy and aim to reconcile clinical evaluations with management information. The system is designed to avoid redundant data collection and to coordinate recommended services, resource allocation, patient tracking, quality evaluations and organizational accountability. These profiles been fully implemented to improve the management of people receiving home care and institutional care in two experimental areas, and the MSSS is now contemplating generalization of the profiles to all home care and institutional services.
Economic evaluation of the implementation and functioning of the PRISMA model5 has also proved useful to policy makers planning implementations of the model and quantifying the budget needed to support it. Additional studies about the work of case managers were also used to better define new professional roles and improve training.6 For example, the Université de Sherbrooke developed a new graduate program for case managers with the input of the PRISMA group.
Occasionally our knowledge translation activities were almost too effective, with some areas deciding to prematurely implement PRISMA work without waiting for final results.
Working in close relationship with policy makers, managers and clinicians ensures the relevance of the group's research and its quick implementation in the health care system. But synchronizing research with services and policy is not always an easy task. Researchers no longer have total control of the experiment, and mutual trust must be established to ensure that policy makers and managers understand the research agenda. Budget constraints have slowed the implementation of ISD in the Estrie area, and of some tools (particularly SIGG), resulting in delays in many research projects. In addition, occasionally our knowledge translation activities were almost too effective, with some areas deciding to prematurely implement PRISMA work without waiting for final results. This was also true at the policy-making level, where the Ministère de la Santé et des Services sociaux included integration and the PRISMA model in his policy for older people. This could have jeopardized our evaluation research, if the selected comparison areas had immediately implemented the PRISMA model.
Conclusions and implications
The PRISMA group has had a major impact on the development of health department guidelines for frail elders experiencing loss of independence.
By working closely with policy makers in Quebec, the PRISMA group has had a major impact on the development of health department guidelines for frail elders experiencing loss of independence7 and an action plan for services to frail older people. PRISMA's work has also influenced the recent provincial reform that set up integrated structures, the Centre de santé et de services sociaux (CSSSs) (merging hospitals, community health centres and nursing homes). The clinical projects for frail older people currently under development in all ninety-five CSSSs will be greatly influenced by PRISMA's work. PRISMA members have also been invited to Ontario and British Columbia to advise regional or provincial authorities on organizing services for older people, and the group recently attended a European conference on providing integrated health and social services for older persons as an international expert.
The PRISMA group continues its research. The Bois-Francs project has demonstrated statistically significant effects on patient functional independence and the utilization of health services.8 As a result of the Estrie study, over the next few years we will be able to document the impact of ISD on health services consumption and determine the related costs through a population-based approach. We will also study ISD impact on professional practices and on frail elders and their immediate caregivers, and develop indicators to assess quality of care within ISD. Indicators are also being developed to measure ISD impact on continuity of services, which is the ultimate objective of integration.
The PRISMA group is also adapting the model for other patient populations, notably those with physical and intellectual disabilities and mental health problems. The validity of the Iso-SMAF profiles has been verified with other patients and their application to private nursing homes is now being tested.
This project demonstrates research can influence policy to improve the Canadian health and social system. The PRISMA group may also have demonstrated the most effective way of combining research with action in order to rapidly and effectively transform research data into new ways of delivering services, and conversely, to ensure that decisions made by government officials and managers are based on solid data.
1 Hébert, R., P. J. Durand, N. Dubuc, A. Tourigny, and the PRISMA Group. 2003. Frail elderly patients. New model for integrated service delivery. Can Fam Physician 49:992-97.
2 Hébert, R., A. Tourigny, et M. Gagnon. 2004. Intégrer les services pour le maintien de l'autonomie des personnes. Quebec: Edisem.
3 Hébert, R., A. Tourigny, and M. Gagnon. 2005. Integrated service delivery to ensure persons' functional autonomy. Quebec: Edisem.
4 Raîche, M., R. Hébert, M-F. Dubois, and the PRISMA partners. User guide for the PRISMA-7 questionnaire to identify elderly people with severe loss of autonomy. In Integrated service delivery to ensure persons' functional autonomy, ed. R. Hébert, A. Tourigny, and M. Gagnon, 147-65. Quebec: Edisem.
5 Durand, S., D. Blanchette, and R. Hébert. 2005. Financial aspects of integrated services for the maintenance of autonomy—implementation and operations. In Integrated service delivery to ensure persons' functional autonomy, ed. R. Hébert, A. Tourigny, and M. Gagnon, 241-55. Quebec: Edisem.
6 Couturier, Y., S. Carrier, and I. Chouinard. 2005. The semantic field of integrating services: Issues for clinical work and planning. Proceedings of the 3rd PRISMA scientific colloquium on integrated services. Prisma.
7 Ministère de la Santé et des Services sociaux. 2001. Orientations ministérielles sur les services offerts aux personnes âgées en perte d'autonomie. Quebec: MSSS.
8 Tourigny, A., P. Durand, L. Bonin, R. Hébert, and L. Rochette. 2004. Quasi-experimental study of the effectiveness of an integrated service delivery network for the frail elderly. Can J Aging. 23 (3): 231-46.
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