F. Beland, H. Bergman, et al. (2001). Establishment and start-up of integrated care model (SIPA: Un système de services intégrés pour personnes âgées en perte d'autonomie. Évaluation de la phase i, juin 1999 à mai 2000). Montreal, Groupe de recherche Universités de Montréal et McGill sur les services intégrés aux personnes âgées.

http://www2.itssti.hc-sc.gc.ca/B_Pcb/HTF/Projectc.ns4/e8009e409c3b461585256be2005c9e75/5c70c8f5b277aac485256816006d766b?OpenDocument&Highlight=0,SIPA

Sponsor Organization:
SOLIDAGE, McGill University-Université de Montréal Research Group on Integrated Services for Older Persons

Rationale/Goals:
Health care planners and providers are concerned about the impact of an aging population on the health care system. At the same time, fragmentation of health care services is often identified as a concern (for all users, but particularly seniors as heavy users of the health care system) as it results in poor communication and system inefficiencies, and affects access to care and its quality. This project tested the feasibility and cost-effectiveness of an integrated system of organizing, financing, and delivering services to the frail elderly, in a way that would support their autonomy and their ability to choose appropriate solutions. From a system viewpoint, the project's goal was to optimize the use of health care resources.

Activities:
The model was implemented in Montreal, at two CLSCs (centres locales de services communautaires), between June 1999 and May 2000. The centres identified and recruited 1,230 eligible clients, and divided them into intervention and control groups. (By the end of the intervention period, the sample size had been reduced to 1,098 through changes of residence, voluntary withdrawal, and mortality.) Multidisciplinary teams coordinated all medical and social services for the SIPA group, including health promotion, rehabilitation, pharmaceuticals, and technical aids. They also dealt with needs for acute and chronic care, and sought to improve collaboration and coordination between institutions. Other features of the model included intensive case management, care protocols, 24-hour on-call services, and a financing system that simulated capitation. (After the HTF funding phase, the project received additional funding from other sources.)

Key Findings:
The project leaders identified the following outcomes:
- Although two years of planning had occurred before funding was secured, and continued for another year before the project became operational, challenges and delays were encountered.
- Particular challenges were encountered regarding the role of physicians in private practice.
- Patients and their caregivers in the intervention group perceived a higher quality of service under the project, and enjoyed a greater sense of security.
- Members of the SIPA group tended to be institutionalized less frequently, and significantly reduced their use of hospital resources - particularly short-term hospitalizations. Emergency departments visits were also shorter, and more likely to result in a return home.
- The difference in mortality rates between the two groups at the end of 12 months of operation (10.5 percent for the SIPA group; 14 percent for the control group) was almost statistically significant.
- Cost analysis found that care costs were slightly higher for the SIPA group. Specifically, there was an increased cost related to the use of community services, which was not fully offset by the reduction in the use of hospital services. However, the authors believe that the model may become more cost-effective when the cost of long-term care is factored in over a longer period.

Implications:
The project leaders indicated that their findings are important because, in their view, SIPA demonstrated its flexibility and succeeded in meeting pressing needs. Despite a very short implementation period, it modified some professional practices, changed the way certain social and health care services are used, and partially modified the distribution of costs between institutional and community services. Since stakeholders in the health care system are increasingly looking to integration of services as a means of addressing current pressures and challenges, this project - with its extensive and detailed evaluation - offers valuable insights into implementing such a process. The report clearly outlines both facilitating factors, and obstacles.

The Montreal regional health board has decided to implement networks of integrated services for its frail elderly population based on the SIPA model.

Evaluation Methodology:
The evaluation focused on four groups: program managers, professionals, participants, and their caregivers. The intervention and control groups were compared on several variables related to patient health and satisfaction, use of services, and cost to the system. Data collection methods included observation, open interviews, questionnaires, medical and hospital records, and administrative files.

R. F. DeBusk, M. B. Fowler, et al. (1997). "A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization." American Journal of Cardiology 79(1): 58-63.

The effectiveness of heart failure management in clinical practice is limited by physicians' suboptimal utilization of effective medication, patients' poor adherence to dietary sodium limitation and optimal drug therapy, and the lack of systematic monitoring of patients after hospitalisation. The present study evaluated the feasibility and safety of MULTIFIT, a physician-supervised, nurse-mediated, home-based system for heart failure management that implements consensus guidelines for pharmacologic and dietary therapy using a nurse manager to enhance dietary and pharmacologic adherence and to monitor clinical status by frequent telephone contact. Fifty-one patients with the clinical diagnosis of heart failure were followed for 138 +/- 44 days. Daily dietary sodium intake fell by 38% from 3,393 to 2,088 mg (p=0.0001); average daily medication doses increased significantly (lisinopril: 17 to 23 mg, p<0.001; hydralazine: 140 to 252 mg, p = 0.01). Compared with the 6 months before enrolment and normalised for variable follow-up, the frequency of general medical and cardiology visits declined by 23% and 31%, respectively (both p<0.03); emergency room visits for heart failure and for all causes declined 67% and 53% respectively (both p<0.001). Hospitalisation rates for heart failure and for all causes declined 87% and 74 % respectively (p=0,.001), compared with the year before enrollment. The MULTIFIT system enhanced the effectiveness of pharmacologic and dietary therapy for heart failure in clinical practice, improving clinical outcomes and reducing medical resource utilisation