Matching Needs of Older

People with Health Care

Management Tools

Prof. Réjean Hébert, MD MPhilResearch Centre on AgingUniversité de Sherbrooke

Sherbrooke, Québec, Canada

Programme de

recherche sur

l’intégration des

services de maintien

de l’autonomie

Programme of

Research to Integrate

the Services for the

Maintenance of

Autonomy

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 Geronto-Geriatrics Research Network

. Sherbrooke Geriatric University Institute

PRISMA

Integrated Network

Operationnalization

Development of Network

Support Tools

Iso-SMAF Profiles

PRISMA-7

Computerized Clinical Chart

Evaluation

Methods

Development

- satisfaction

- empowerment

- quality of services

- economic evaluation

- continuity indicators

- implementation evaluation

Experimental implementation and impact evaluation

. Bois-Francs Project

. Estrie Project

Integrated Network of Services

• Coordination between services

• Single point of entry

• Case-management

• Individualized Service Plan

• Unique assessment tool with a Casemix

system

• Information tool (Computerised Chart)

Assessment Problems

• Multiple entry points

• Services determined by

the provider rather than

the needs

• Multiple redundant

assessments (different

tools)

• Information sharing

• Partial response to the

needs

System « schizophrenia »

Needs assessment

Services prescription

Resources allocation

Follow-up and quality assessment

Data collection

Budget allocation

Accountability

Clinical path Management path

Reconciliating

clinical and management

Needs assessment

Services prescription

Resources allocation

Follow-up and quality assessment

Data collection

Budget allocation

Accountability

Clinical path Management path

Advantages

• Avoid redondant evaluation

• Data collection for management less fakable

• Accountability and quality assessment are

more consistent

SMAF

• Système de Mesure de l’Autonomie Fonctionnelle(Functional Autonomy Measurement System)

• Developed according to the WHO Classification

of disabilities

• 29 items on a 5-point scale– 0: autonomous– -0.5: with difficulty– -1: need supervision– -2: need help– -3: dependent

Items of the SMAF

• Activities of Daily Living

– eating

– washing

– dressing

– grooming

– urinary continence

– fecal continence

– using the bathroom

• Mobility

– transfers

– walking outside

– walking outside

– donning a prosthesis & orthesis

– propelling a wheelchair

– negociating stairs

Items of the SMAF (suite)

• Communication

– vision

– hearing

– speaking

• Mental functions

– memory

– orientation

– judgement

– behaviour

• Instrumental Activities of Daily

Living

– housekeeping

– preparing meals

– shopping

– doing the laundry

– using the telephone

– using public transportation

– taking medications

– managing the budget

SMAFReliability & Responsiveness

• Test-retest reliability (n=39)

– ICC= 0.95

• Inter-rater reliability (n=45)

– ICC= 0.96

• Minimal Metrically Detectable Change (measurement

error)

– 5 points and over

• Responsiveness (n = 80)

– Guyatt index: 14.5

(FIM: 13.7; Barthel: 12.8)

SMAF

Validity• Content

– WHO Theoritical framework

– Consultations with experts

• Construct

– Correlation with nursing time

• r=0.92 (n=1997)

– Correlation with cost

• r=0.75 (n=1997)

– Discrimination between institutions

– Correlation with other func. scales

• FIM: r= 0.94

• Barthel: r= 0.92 (n= 80)

Total SMAF score

100806040200

Re

qu

ire

d n

urs

ing

tim

e (

ho

urs

/da

y)

8

6

4

2

1

,8

,6

,4

,2 Rsq = 0,8504

Correlation with nursing care

time

Distribution of SMAF scores

SMAF score (/3)

3.02.52.01.51.0.50.0

ADL

Mobility

Communication

Mental Functions

IADL

Home-dwelling

Intermediate facilities

Nursing homes

Cost associated with

disabilities (n=1345)

Total SMAF scoreTotal SMAF score

100806040200

To

tal

To

tal c

os

t c

os

t ( (C

an

Ca

n$

/$

/ da

yd

ay))

400

200

100

80

60

40

20

10

Type ofType of setting setting

nursing homenursing home

RsqRsq = 0,6811 = 0,6811

intermediateintermediate

RsqRsq = 0,1529 = 0,1529

home-home-dwellingdwelling

RsqRsq = 0,5479 = 0,5479

150

70

$80

ISO-SMAF Profiles(Dubuc et al, 2001)

• Case-mix classification system

– RUG-type

• Developed by Cluster analysis (n=1997) and

expert consultation

• Validation– internal: split samples– external: discrimination of nursing care time and

costs

• 14 groups

PROBLEMS IN INSTRUMENTAL

ACTIVITES OF DAILY LIVING ONLY

PREDOMINANT ALTERATIONS

IN MOBILITY FUNCTIONS

HELP IN MOBILITY

BEDRIDDEN AND DEPENDENCY IN ADL

PREDOMINAN T ALTERATIONS

IN COGNITIVE FUNCTIONS

MIXED ALTERATIONS

MOBILITY + COGNITIVE

Autonomous (0)

Difficult ies (0,5)

Supervision (1)

Help (2)

Dependence (3)

Legend

Difficulties

ADL MOBCOM MF IADL

SupervisionADL MOB COM MF IADL

Help

ADL MOB COM MF IADL

Autonomous ADL

ADL MOBCOM MF IADL

Difficulties ADL

Without incontinence

With incontinence(Majors behavioral problems)

ADL

ADL

MOB

MOB

COM

COM

MF

MF

IADL

IADL

Moderate + difficulties ADL

Severe + difficulties ADL

Severe + supervision mobil ity

Severe cognitive impaiment

Severe + help ADL(walke independently, behavioral problems)

Very severe cognitive impaiment(moderate behavioral problems)

ADL

ADL

ADL

ADL

ADL

ADL

MOB

MOB

MOB

MOB

MOB

MOB

COM

COM

COM

COM

COM

COM

MF

MF

MF

MF

MF

MF

IADL

IADL

IADL

IADL

IADL

IADL

Help ADL

ADL

ADL

MOB

MOB

COM

COM

MF

MF

IADL

IADL

49,0

9

59,0

12

23,0

4

20,0

13,5

2

9,0

1

32,0

6

59,0

11

52,0

10

43,0

8

74,0

14

65,5

13

39,0

7

29,0

5

3

PROBLEMS IN INSTRUMENTAL

ACTIVITIES OF DAILY LIVING ONLY

DifficultiesADLMOBCOMMF IADL

Supervision

ADLMOBCOM MF IADL

Help

ADLMOBCOM MF IADL20,0

3

13,5

2

9,0

Autonomous (0)

Difficulties (0,5)

Supervision (1)

Help (2)

Dependence (3)

Legend

PREDOMINANT ALTERATIONS

IN MOBILITY FUNCTIONS

Autonomous ADL

ADL MOBCOM MF IADL

Difficulties ADL

ADLMOBCOM MF IADL

Help ADL

ADL MOBCOM MF IADL

49,0

9

23,0

4

32,0

6

Autonomous (0)

Difficulties (0,5)

Supervision (1)

Help (2)

Dependence (3)

Legend

PREDOMINANT ALTERATIONS

IN COGNITIVE FUNCTIONS

Moderate + difficulties ADL

Severe + difficulties ADL

Severe + supervision mobility

Severe + help ADL(walke independently, behavioral problems)

ADL

ADL

ADL

ADL

MOB

MOB

MOB

MOB

COM

COM

COM

COM

MF

MF

MF

MF

IADL

IADL

IADL

IADL

52,0

10

43,0

8

39,0

7

29,0

5

Autonomous (0)

Difficulties (0,5)

Supervision (1)

Help (2)

Dependence (3)

Legend

HELP IN MOBILITY

Without incontinence

With incontinence

ADLMOBCOM MF IADL

ADLMOBCOM MF IADL

59,0

12

59,0

11

Autonomous (0)

Difficulties (0,5)

Supervision (1)

Help (2)

Dependence (3)

Legend

BEDRIDDEN AND DEPENDENCY IN ADL

Severe cognitive impaiment

Very severe cognitive impaiment(moderate behavioral problems)

ADL

ADL

MOB

MOB

COM

COM

MF

MF

IADL

IADL

74,0

14

65,5

13

Autonomous (0)

Difficulties (0,5)

Supervision (1)

Help (2)

Dependence (3)

Legend

ISO-SMAF Profiles

• Functions:

– Service prescription: admission criteria

– Monitoring

– Management of resources

– Financing

4, 6 and 9

11, 12, 13 and 14

1, 2 and 3

5, 7, 8 and 10

Instrumental activities daily living

Mobility

Mental functions

Mixed and heavy disabilities

100%

40%10%35%15%

Profile of a LTC facility(Tousignant et al. Age and Ageing, 2003)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

IUGS

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

MobilityIADL Mental Mixed

Distribution ISO-SMAF profiles of a LTC facility

Distribution of ISO-SMAF profiles of a LTC facility

0% 20% 40% 60% 80% 100%

Carrefour santé du Granit

(N=116)

CLSC-CH-CHSLD MRC

Asbestos (N=96)

CLSC-CHSLD Haut-St-François

(N=100)

Carrefour sss du Val-St-

François

Carrefour sss CLSC-CHSLD

MRC Coaticook (N=89)

CLSC- CHH Memphrémagog

(N=130)

La Maison Blanche de North

Hatley Inc. (N=60)

Centre d'accueil Shermont Inc.

(N=51)

Maison Reine-Marie Inc. (N=48)

CHSLD l'Estriade (N=379)

IUGS (N=386)

Région de l'Estrie (N=1590)

profil 1

profil 3

profil 4

profil 6

profil 9

profil 5

profil 7

profil 8

profil 10

profil 11

profil 12

profil 13

profil 14

MobilityIADL Mental Mixed

Standard budget

(ISOSMAF-based)

Profile 3 :

$ 68.48

Profile 4 :

$ 100.74

Profile 5 :

$ 78.42

Profile 6 :

$ 90.89

Profile 7 :

$ 98.78

Profile 8 :

$ 114.96

Profile 9 :

$ 147.76

Profile 10 :

$ 129.70

Profil e11 :

$ 159.02

Profile 12 :

$ 144.81

Profile 13 :

$ 169.63

Profile 14 :

$ 183.19

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

IUGS

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

10 profiles 7 � $ 98.78 $

50 profiles 9 � $ 147.76 $

150 profiles 13 � $ 169.63 $

Le budget standard ISO-SMAF et le budget disponible

présenté par établissement

18 661 178 $

14 610 327 $

2 389 823 $

1 937 723 $

2 201 419 $

6 759 347 $

5 149 136 $

5 548 173 $

8 100 285 $

9 669 835 $

4 428 917 $

22 773 450 $

21 692 976 $

2 782 931 $

2 662 467 $

2 242 907 $

7 991 441 $

6 784 084 $

6 726 120 $

9 378 250 $

12 851 823 $

5 373 118 $

- $ 5 000 000 $ 10 000 000

$

15 000 000

$

20 000 000

$

25 000 000

$

IUGS

CHSLD Estriade

Centre d'accueil

Shermont Inc.

Maison Reine-Marie Inc.

Maison Blanche de North

Hatley

Carrefour santé du

Granit

CLSC - CHSLD du Haut-

St-François

CLSC, CH et CHSLD

MRC d'Asbestos

Carrefour s.s.s. du Val

St-François

CLSC - CHH

Memphrémagog

Carr. s.s.s. CLSC-

CHSLD Coaticook

Budget théorique standard ISO-SMAF

Budget disponible

• ISO-SMAF-based funding

• Traditional funding

Pourcentages des besoins comblés

par le budget standard ISO-SMAF par rapport au budget disponible

présentés par établissement

82%

67%

86%

73%

98%

85%

76%

82%

86%

75%

82%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

0% 20% 40% 60% 80% 100% 120%

IUGS

CHSLD Estriade

Centre d'accueil Shermont

Inc.

Maison Reine-Marie Inc.

Maison Blanche de North

Hatley

Carrefour santé du Granit

CLSC - CHSLD du Haut-St-

François

CLSC, CH et CHSLD MRC

d'Asbestos

Carrefour s.s.s. du Val St-

François

CLSC - CHH

Memphrémagog

Carr. s.s.s. CLSC-CHSLD

Coaticook

Budget standard ISO-SMAF

Budget disponible

• ISO-SMAF-based funding

• Traditional funding

Computerized clinical chart(Tourigny et al, 2002)

• SIGG (Système d’information géronto-

gériatrique)

• Version 3.0

• Implemented in 2 regions as part of an

integrated network

• Continuous monitoring of clients

• linked to administrative data base

Conclusion

• Reconciliate clinical and management needs

• Decrease assessment burden for clients,

managers and clinicians

• Continuous monitoring of needs– prescription of services

– resources allocation

– fair financing

– accountability

– planning

www.prisma-qc.ca

Rejean.hebert@USherbrooke.ca