Matching Needs of Older
People with Health Care
Management Tools
Prof. Réjean Hébert, MD MPhil
Research Centre on Aging
Université 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
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
Integrated Network of Services
• Coordination between services
• Single point of entry
• Case-management
• Individualized Service Plan
• Unique assessment tool with a Casemix
system
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
System « schizophrenia »
Needs assessment
Services prescription
Resources allocation
Follow-up and
quality assessment
Data collection
Budget allocation
Accountability
Reconciliating
clinical and management
Needs assessment
Services prescription
Resources allocation
Follow-up and
quality assessment
Data collection
Budget allocation
Accountability
Advantages
• Avoid redondant evaluation
• Data collection for management less fakable
• Accountability and quality assessment are
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
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
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
SMAF
Reliability & 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
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
Total SMAF score
100 80 60 40 20 0Re
quir
e
d
nu
rsin
g t
im
e
(h
our
s/d
a
y)
8 6 4 2 1 ,8 ,6 ,4 ,2Rsq = 0,8504
Correlation with nursing care
time
Distribution of SMAF scores
SMAF score (/3)
3.0 2.5 2.0 1.5 1.0 .5 0.0ADL
Mobility
Communication
Mental Functions
IADL
Home-dwelling
Intermediate facilities
Nursing homes
Cost associated with
disabilities
(n=1345)
Total SMAF score
Total SMAF score
100 80 60 40 20 0
To
ta
l
To
ta
l
co
st
co
st
(
(
Ca
n
Ca
n
$/
$/
da
y
da
y
)
)
400 200 100 80 60 40 20 10Type of
Type of
setting
setting
nursing home nursing home Rsq Rsq = 0,6811 = 0,6811 intermediate intermediate Rsq Rsq = 0,1529 = 0,1529 home-home-dwellingdwelling Rsq Rsq = 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
PROBLEMS IN INSTRUMENTAL
ACTIVITES OF DAILY LIVING ONLY
PREDOMINANT ALTERATIONS
IN MOBILITY FUNCTIONS
HELP IN MOBILITY
BEDRIDDEN AND DEPENDENCY IN ADL
PREDOMINANT ALTERATIONS
IN COGNITIVE FUNCTIONS
MIXED ALTERATIONS
MOBILITY + COGNITIVE
Autonomous (0) Diffic ult ies (0,5) Superv ision (1)
Help (2)
Dependence (3)
Legend
Difficulties ADL MOB COM MF IADL Supervision ADL MOB COM MF IADL
Hel p ADL MOB COM MF IADL
Aut onomous AD L ADL MO B COM MF IADL
Di fficul ties ADL
Without incontinence
With incontinence
(Majors behavioral problems)
ADL ADL MOB MOB COM COM MF MF IADL IADL
Moderate + difficul ties ADL
Severe + diffic ulties ADL
Severe + supervisi on mobil ity
Severe cognitive impaiment Severe + help ADL
(walke independently, behavioral problems)
Very severe cognitive impai ment
(moderate behavioral problems)
ADL ADL ADL ADL A DL ADL MO B MOB MOB MO B MOB MOB COM COM COM C OM C OM COM MF MF MF MF MF MF IA DL IA DL IA DL IADL IADL IA DL Help AD L ADL ADL MO B MO B COM COM MF MF IADL IADL 49,0
9
59,012
23,04
20,0 13,52
9,01
32,06
59,011
52,010
43,08
74,014
65,513
39,07
29,05
3
PROBLEMS IN INSTRUMENTAL
ACTIVITIES OF DAILY LIVING ONLY
Difficulties
ADL MOBCOM MF IADL
Supervision
ADL MOBCOM MF IADL
Help
ADL MOBCOM MF IADL
20,0
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
ADL MOBCOM 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
ADL MOBCOM MF IADL
ADL MOBCOM 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
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 14Mobility
IADL
Mental Mixed
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
Mobility
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