SIPA. An integrated system of care for frail elderly persons

Transcription

1 SIPA. An integrated system of care for frail elderly persons François Béland, PhD Département d administration de la santé Université de Montréal Co-Directeur, SOLIDAGE Groupe de recherche Université de Montréal et McGill sur les services intégrés aux personnes âgées. Réseau canadien de recherche pour les soins dans la communauté, Toronto, 23 Octobre 2006 Hôpital général juif Sir Mortimer B. Davis Jewish General Hospital Centre d épidémiologie clinique et de recherche en santé publique, Institut Lady Davis Centre for Clinical Epidemiology and Community Studies, Lady Davis Institute Université de Montréal Département d administration de la santé Groupe de recherche Interdisciplinaire en santé (GRIS) McGill The Dr. Joseph Kaufmann Chair in Geriatric Medicine La Chaire D r Joseph Kaufman en gériatrie Centre de recherche Institut universitaire de gériatrie de Montréal

2 SIPA. An integrated system of care for frail elderly persons François Béland PhD Howard Bergman MD Paule Lebel MD Pierre Tousignant, Johanne Monette, Jean Louis Denis, André-Pierre Contandriopoulos, Francine Ducharme, Jean-François Boivin, Stan Shapiro Kathy Lesperance, Luc Dallaire, Cristian Morales, Claude Richard, Denis Roberge, Nassera Touati, Ellen Leibovitch Collaboration internationale David Challis, A. Mark Clarfield, Jack Guralnik, Robert Kane Hôpital général juif Sir Mortimer B. Davis Jewish General Hospital Centre d épidémiologie clinique et de recherche en santé publique, Institut Lady Davis Centre for Clinical Epidemiology and Community Studies, Lady Davis Institute Université de Montréal Département d administration de la santé Groupe de recherche Interdisciplinaire en santé (GRIS) McGill The Dr. Joseph Kaufmann Chair in Geriatric Medicine La Chaire D r Joseph Kaufman en gériatrie Centre de recherche Institut universitaire de gériatrie de Montréal

3 SIPA. An integrated system of care for frail elderly persons L équipe de direction clinique: Luce Beauregard, Régie régionale de la Santé et des Services sociaux de Montréal-Centre Diane Boutin, Danielle Dubois et Michel Lemieux, Centre local de services communautaires Bordeaux-Cartierville Lorraine Bouvier, Myriam Proulx Centre local de services communautaires Côte-des-Neiges Hôpital général juif Sir Mortimer B. Davis Jewish General Hospital Centre d épidémiologie clinique et de recherche en santé publique, Institut Lady Davis Centre for Clinical Epidemiology and Community Studies, Lady Davis Institute Université de Montréal Département d administration de la santé Groupe de recherche Interdisciplinaire en santé (GRIS) McGill The Dr. Joseph Kaufmann Chair in Geriatric Medicine La Chaire D r Joseph Kaufman en gériatrie Centre de recherche Institut universitaire de gériatrie de Montréal

4 For further information on SIPA:

5 Topics: SIPA: What it is! Results from the experimental demonstration project. Some lessons.

6 SIPA: What it is!

7 SIPA: «Système de soins Intégrés pour Personnes Âgées fragiles» Community-based system of care responsible for the full range of services: Social and health care, acute and long-term care, communityand institution-based including acute care hospitalizations, convalescence care, nursing homes, prescribed drugs, etc. Responsibility for health outcome, utilization and costs of services for the population of frail elderly persons in a specific catchment area Integration of social and health care through: Case management Multi-disciplinary team Care guidelines and protocols based on best practices

8 SIPA: An integrated system of care for frail elderly persons A responsive organization able to mobilize resources flexibly and rapidly to meet needs, and avoid inappropriate utilization: Availability of intensive community services; Early detection and intervention in: Medical, social and rehabilitation needs and services. Fast communication and response to frail elderly person, and their family, needs: On call services, providers linkages; Pre-payment with per capita budget with financial responsibility for the full range of services. Integrated with Canadian Medicare: Universal, single payer, and publicly managed.

9 A SIPA Team Full time equivalent Average # of frail elderly persons Regional management Local manager 1 per SIPA site 320 Team managers 2 per SIPA site 160 Care managers 4 40 Nurses 2,5 64 O.T P.T Nutritionist 0,5 320 Social worker Community worker 0,5 320 Pharmacist Homemakers 7,5 21 SIPA s physician 0,5 320 Family physician 160 2

10 Issues and Hypotheses Study the feasibility of SIPA: Implementation and management Observed changes in health status: No change in health or functional outcomes Evaluation of quality of care: Equivalent or improved quality of care, comparable or improved quality of life and increased satisfaction in the SIPA group Estimate changes in patterns of health services utilization: Integration of health and social care Change in the configuration of utilization by decreasing acute hospital use (in-patient and ER) and institutional-based LTC Estimate and compare costs: Cost neutral, or decrease total costs

11 Random control trial: results of case allocation Total number of of participants: 1230 Site Site 1: 1: Site Site 2: 2: SIPA: SIPA: Control: SIPA: SIPA: Control:

12 Data sources Implementation (12 months): 78 open interviews with staff Non-obstrusive observations of decision-making processes Documents Quality of care (12 months): CSQ-8 Case studies Utilization and costs (22 months): Physicians payment, drugs and prostetic equipments (RAMQ) Hospitalizations, emergency, outpatient clinics (MEDécho; records) Institutionalization (RRSSSM-C) Community home-based care (SICC) Health status (12 months): Questionnaires to participants (T0 and T1); and caregivers (T1)

13 Results from the evaluation

14 Implantation and organization Achieved: Clinical responsibility over the span of services and agencies On call services, information sharing between care providers, rapid and flexible use of resources Interdisciplinarity SIPA s physicians involve in the multidisciplinary team Partially achieved: Case management: learning process Financial responsibility: concerned with costs Weaknesses: Cooperation with family physician did not work, but some documented cases of exchange with the SIPA team Collaboration with partners (hospitals, nursing homes, day centers)

15 Quality of care Perceived quality of care is higher in the SIPA group; Case study: Room for improvements in the management of specific health problems Insufficient use of protocols (diabetes, falls, depression, chronic heart failures, drugs ) : Frequency of use less than expected Follow-up The analysis of critical events does not reveal poor management.

16 Health status: Same at T0 and T1 Measurements N(T0) N(T1) Ranges Control T0 ( ) Control T1 ( ) SIPA T0 ( ) # chronic diseases ,0 4,8 4,9 5,0 No Barthel (#) ADL (#) ,0 6,6 6,9 7,6 Incontinence (@) % 46,4% 46,6% 41,9% 42,0% No Reduced level of activity (@) Functional limitations SIPA T1 ( ) % 40,2% 36,3% 41,9% 37,4% No ,7 10,3 9,8 10,3 Perceived health ,4 3,4 3,5 3,3 Depression (GDS) % 13,9% 10,9% 12,5% 10,4% Cognitive problems % 32,3% 24,3% 31,5% 26,3% No P 0,0 5 No No No No No Moyennes ou proportions observées au temps 1 des groupes expérimental et Analyse de régression logistique avec variable dépendante dichotomique. # Une transformation logarithmique a été appliquée à la variable pour l estimation de l effet SIPA.

17 Costs for institutional-based services $ $ $ $ $ $ $ $ $ 0 $ $ $ Emergency Department $ $ $ Control SIPA $ $ $ Acute in-patient LTC in Acute bed* Nursing homes * Significatif à p<0,05

18 Costs for community-based services $ $ $ $ $ $ $ $ Contgrol SIPA $ $ $ $ $ $ 500 $ 0 $ Home nursing Homemaking Prescribed $ $ MD Specialists 227 $ 283 $ MD General care* Drugs Practiioners* * Significatif à p<0,05

19 # of chronic illnesses (CI) and SIPA-Control differences in costs for nursing home care $ $ $ $ $ $ 500 $ 0 $ 572 $ 547 $ 2 or less 3 to 4 5 to 6 7 or more

20 # of chronic illnesses (CI) and SIPA-Control differences in costs for institutionalization $ $ -585 $ $ $ $ $ $ 4 CI or less 5 CI or more

21 Living alone and SIPA-Control differences in costs for institutionalization $ $ $ 0 $ $ $ $ $ $ Live with other Live alone

22 Disability in IADL and SIPA-Control difference in costs for acute in-patient care $ $ $ 0 $ $ $ $ $ $ $ $ None Low Average High

23 Total costs, and costs for community- and institutional-based services $ $ $ $ $ $ Control SIPA $ $ $ $ $ $ $ 0 $ Community* Institution* Total Average over 1223 participants Community-based care: Prescribed drugs, visits to physicians, home health and social care, protected housing, day care and day hospitals, out-patient rehab. Intitutional-based care: Acute in-patient, institutionalization, visits to ER, in-patient rehab, paliative care.

24 Average total daily costs for deceased persons and survivors 150 $ 140 $ 130 $ 120 $ 110 $ 100 $ 90 $ 80 $ 70 $ 60 $ 50 $ 40 $ 30 $ 20 $ 10 $ 0 $ 54$ 139$ Survivors Deceased 54$ 123$ Average SIPA-Control 151$ differences in costs over average surviving period (343 days): 9604$ 55$ Total* SIPA Control * Significant at p<0,05 SIPA-Control significant for deceased persons only

25 Lessons and take home

26 Conditions for a successful implementation of SIPA: Clinic Integration of community-based social and medical care with easy and fast referal and consultation with geriatric and psycho-geriatric services Integration of family physicians with, or within, the SIPA team Interdisciplinary protocols and guidelines for screening and care targeted to main sources of disability and chronic diseases Identification of persons, and caregivers, with highly complex needs for integrated services in the community Care management as a clinical practice, not a management position The frail elderly person social and physical environments should be integrated within the care plan

27 Conditions for a successful implementation of SIPA: Management A management system: Respectful of: Frail elderly persons and caregivers Staff delivering the services Promote decision making by persons responsible for care delivery Promote imputability by staff and management Needs for information systems: Useful at the clinical level Useful for those delivering the services Useful for managing and assessing care Useful for assessing responsiveness to needs Quality assurance at all levels, clinical and managerial: Needs for indicators Needs for the integration of quality assessment at the day to day clinical level. Training, training, training everyone, from homemakers to nurses, to physicians

28 Conditions for a successful implementation of SIPA: Financing Financing should promote: Community-based care Flexible use of services at the level of frail elderly persons Performance and imputability: To target population To regional and ministerial authorities Financing should be base on population-level needs for services to frail elderly persons in a catchment area