A system of intgrated care For older persons with disabilities in Canada: Results from an RCT
Elderly people with significant functional disabilities, those typically over 75 years old, account for roughly 20% of the elderly population but disproportionately use acute hospital and nursing home care and have frequent transitions between the two. This creates a challenge both in providing quality and efficient care.
Part of this challenge is a result of the current fragmented system and has led to an increased interest in developing more integrated models that might improve overall health , satisfaction and utilization outcomes. Although these models do exist, there have been relatively few published studies using a randomized control trial or quasi experimental methodology.
Béland and colleagues (2006) developed a randomized control trial tracking the outcomes of 1230 elderly adults randomly assigned to a control or intervention group over a 22 month period. To be included in the study elderly adults must have been at least 64 years old, community dwelling, residing within one of two predefined geographic areas, competent in French or English and have a participating caregiver (if a caregiver existed). Participants were included only if they scored a -10 (moderate disability) or less on the Functional Autonomy Measurement System (SMAF) scale (15).
The intervention group participants were enrolled in the SIPA (French acronym for System of Integrated Care for Older Persons) program. SIPA is a pre-existing program of ‘community - based multidisciplinary health care teams responsible for delivering integrated care through the provision of community health and social services and the coordination of hospital and nursing home (NH) care within the publicly managed and funded system’. The control group participants received (if needed) the usual array of home care services with no overarching case management.
Outcome measures included differences between SIPA and control for admissions, service utilization (total hours or days over the study period), public costs of inpatient care, alternate level of care (ALC – patients who remain in hospital after treatment awaiting NH placement), NH, home health and social care. Total costs (institutional, community and overall) were also compared as were health status , satisfaction with care, out-ofpocket expenses and caregiver burden for the first 12-month period.
Overall results showed an increase for health and social home care among the SIPA group with a 50% reduction in ALC stays among the SIPA group. Although there were cost differences between home care and institutional costs between the two groups the net overall health care costs difference between the two groups was negligible. Satisfaction amongst SIPA caregivers was increased and there was no increase in caregiver burden or out-ofpocket costs for this group. There were no differences in overall health outcomes between the groups. The authors concluded that the integrated system as delivered to the experimental group through SIPA has the potential to reduce hospital and nursing home utilization without increasing health care costs.