SIPA: A SYSTEM OF INTEGRATED CARE FOR VULNERABLE ELDERS IN CANADA. RESULTS FROM AN RCT

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SIPA A SYSTEM OF INTEGRATED CARE FOR VULNERABLE
ELDERS IN CANADA. RESULTS FROM AN RCT
www.solidage.ca Groupe de recherche Université de
Montréal/McGill sur les services intégrés pour
les personnes âgées McGill/Université de
Montréal Research Group on Integrated Services
for Older Persons

• F Béland (1) , H Bergman (1) , P Lebel (3) ,
• AM Clarfield (5) , P Tousignant (4) ,
• AP Contandriopoulos (2) , L Dallaire (1) , S
  Hummel (1)
• (1) Solidage, Université de Montréal McGill
  University Research Group on Integrated Services
  for Frail Elderly Persons.
• (2) DASUM, Université de Montréal
• (3) Institut universitaire de gériatrie de
  Montréal
• (4) Direction de la santé publique, ARSSS,
  Montréal
• (5) Ben Gurion University
• INIC, Dublin, 14-15 Février

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Characteristics of Older Persons with
disabilities

• Generally over 75
• Disabilities in ADL/IADL
• Acute and chronic medical problems
• Importance of social network
• Frequent transitions community, hospital, rehab,
  NH
• Need for a complex combination of medical and
  social services

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SIPA the Process

• Partnership
• Ministry
• Regional Board decision-makers and administrators
• Hospital, home-care and Nursing Home managers
• Clinicians
• University-based researchers
• Advisory board
• Interdisciplinary committee on clinical practice

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Characteristics of SIPAIntegrated System of Care
for the Frail Elderly

• Community primary care based system responsible
  for the full range of services
• Health and social services, acute and long-term
  care community, hospital and institutional
• Responsibility (health outcomes, utilisation) for
  a defined population on a defined territory (not
  implemented)
• Consolidated case management
• in partnership with family MD
• with clinical responsibility and accountability
• for the full range of services
• Integration of medical and social care based on
  interdisciplinary protocols

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Characteristics of the SIPAIntegrated System of
Care for the Frail Elderly

• A responsive organization able to mobilize
  resources flexibly and rapidly to meet needs,
  avoid inappropriate utilization
• Increased intensity of community care
• Early detection and intervention (medical,
  rehabilitation, social)
• Rapid communication and response
• On call
• Provider linkage
• Financing through capitation (not implemented)
• Universal, single payer, publicly managed

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SIPA intervention staff

• Two multidisciplinary teams per site
• 160 patients per team
• 4 case managers (nurse or social worker)
• 2 community nurses
• 0.5 SW
• 0.5 OT
• 0.5 PT
• 15 homemakers
• 0.5 consultant pharmacist in one site
• Part-time staff physician

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SIPA InterventionPhysicians

• Patients encouraged to continue with own
  community family physician (mainly office-based)
• Usual fee-for-service plus 400/SIPA/patient/year
• Part-time SIPA staff physician
• Salary
• Small SIPA primary care case load
• Backup and resource to team and community family
  physician (e.g. for urgent or more intensive
  intervention)
• On site geriatric consultation in one site

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SIPA InterventionAssessment and management

• Multidisciplinary team responsible for assessing
  needs, organizing and delivering most of health
  and social services in community in collaboration
  with primary care physician
• Comprehensive geriatric assessment on entry
• Evidence based interdisciplinary protocols
  development
• Nutrition, falls, CHF, dementia, depression,
  medication, vaccination
• Rapid communication, mobilisation of resources
• Intensive home care, group homes
• 24 hour nurse on call with MD backup

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SIPA InterventionCase Management

• Consolidated case management with
  multidisciplinary team
• Intervention with patients and caregivers
• Liaison with family MD and specialists
• Maintain clinical responsibility
• Actively followed patients throughout trajectory
  of care including in hospital
• Assure continuity
• Ease transitions

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Control Intervention

• Usual CLSC home care
• Multidisciplinary team evaluation based primarily
  on service provision
• Services nursing, social services, help with
  ADL limited PT, OT, MD
• Essentially no case management
• No on call limited weekend availability
• Little continued/flexibility over budget no
  budget for group homes
• No responsibility/accountability for clinical and
  utilization outcomes outside of home care services

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Hypotheses

• Shifting utilisation and costs from
  institutional-based to community-based services
• Increase in home health and social care
• Decrease in ED, in-patient, long-term stays in
  acute care hospitals, and SNH
• And
• Public per capita costs in the SIPA group,
  including the grant, will be equivalent or
  decreased compared to the control group
• No increase in participants, and their caregivers
  burden
• Out-of-pocket costs
• Self-perceived burden
• Higher level of participants and caregivers
  satisfaction with care
• No differences in health status among SIPA and
  control group

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Recruitment and Randomization
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Length of participant enrollment

• Duration of trial 669 days
• Participants
• 57.1 were enrolled for whole period
• Average length of enrollment
• 572 days

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Baseline SES Characteristics
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Baseline Health Status Characteristics
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Average Costs per Study ParticipantTotal,
community and institutional-based services
Significant at the p0,05
Services communautaires Médicaments, visites
médicales, soutien à domicile, résidences
protégées, appareils techniques, hôpitaux de
jours. Services institutionnelles
Hospitalisation de courte durée, hospitalisation
dun jour, hébergement, urgences hospitalières,
réadaptations
institutionnelles, soins palliatifs
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Access to institutional-based services
Significant at the p0,05
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Costs of institutional-based services
Significant at the p0,05
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Supplementary analyses Differences in Costs
Between SIPA and Control
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Conclusion

• SIPA changed the overall pattern of use and costs
  of health and social care
• How were these results achieved
• Decrease in proportion of bed-blockers
• Small and cumulative decrease in use and costs of
  institutional-based services
• Increase in availability of nursing, OP and OT
  home care
• Decreasing long-term stays in acute care
  hospitals is a significant achievement in the
  Montréal context
• Most important changes occurred in the most
  disabled participants
• Burden of care for participants and their
  caregivers was not increased

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Conclusion

• Our results are consistent with those reported
  for similar models developed in the United
  States. This, and these other trials results,
  demonstrate the potential to change the
  configuration of utilization of services