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Introduction : Examiner les trajectoires des personnes de 65 ans et plus en fin de soins actifs (FDSA) aux deux hopitaux de Sherbrooke, QC par leurs transitions apres leur sortie de l’hopital.Methodes : Trois bases de donnees ont ete jumelees : hospitalisations, visites a l’urgence et hebergements. La periode d’etude est de janvier 2011 a decembre 2015. L’etude inclut seulement les personnes en FDSA. L’analyse statistique fut realisee avec le logiciel SPSS.Resultats : Le quart des personnes en FDSA ont attendu moins de sept jours et 74 % moins de trois semaines. Dans 64,9 % des cas, les personnes furent transferees en service de longue duree, 15,2 % sont retournes a leur domicile ou a une residence privee et 15,9 % ont ete orientees vers une ressource intermediaire. Suite a leur sortie, la moitie des personnes ont demenage vers un autre milieu, surtout celles a domicile ou dans une residence. Les jours-presence en FDSA ont represente 1 % des jours possibles et moins de 2 % des lits dans 86,4 % des jours. Seules 12 % des personnes sont retournees a l’hopital dans les 90 jours suivant leur sortie.Conclusions : L’occupation de lits d’hopital par des personnes FDSA ne semble pas compromettre la capacite de l’hopital. Les 12 % de retours en moins de 90 jours confirment une bonne orientation de la majorite de ces personnes. Nos resultats suggerent une bonne gestion des transferts et une offre adequate d’hebergement et des services a domicile.

The identification of the older people who are functionally dependant is essential for planning interventions with emphasis on secondary and tertiary prevention. Therefore, a simplified tool, able to identify these individuals for a more comprehensive evaluation, is required. However, the use of a measuring tool in a different socio-cultural context requires prior adaptation. This article aims to verify the psychometric properties of the PRISMA-7 in Brazilian context. This instrument was previously shown as able to identify older persons living in the community who have risk of functional loss in a Canadian study. In a sample of 1748 older persons, the internal consistency assessed by Cronbach's alpha showed a borderline value credited to the reduced number of questionnaire items. Factor analysis identified two well correlated factors, except for items 2 and 6. For criterion validity the SMAF scale (French acronym, Functional Autonomy Measurement System) was used as the gold standard. The analysis of the ROC curve indicated a sensitivity of 74.4% and specificity of 87.4% for the cut-off point of 4, while the Canadian version had a cut-off point of 3 for disability detection. Inter and intra-observer reliability, investigated by the Kappa Cohen were high and statistically significant. In conclusion, the results suggest that the validation process was adequate, and recommend the Brazilian version of PRISMA-7, to track older people with functional loss in the community.

To determine the palliative care pathways of older patients in Sherbrooke, Qc by examining their transfers to other facilities.This analysis was conducted by linking 3 databases: emergency department, hospitalizations and nursing homes. The study period ranged from January 2011 to December 2015. SPSS was used for statistical analysis. The study only included palliative care patients.25% of patients waited less than 7 days for transfer, and 74% waited less than 3 weeks. 64.9% of patients were transferred to a long-term facility for dependent adults (LTF), 15.2% returned home or were transferred to private accommodation, and 15.9% were transferred to an intermediate care facility. One-half of patients subsequently changed facility, mainly those in homes or intermediate care. Palliative care patient bed occupation rates represented 1% of available bed-days and less than 2% of total beds for 86.4% of days. Only 12% of patients returned to hospital within 90 days after discharge.The number of beds occupied by palliative care patients does not seem to disrupt the hospital capacity. The majority of the palliative care patients were well managed, as reflected by the low readmission rate. Our results indicate good management of transfers and an adequate supply of long-term care facilities and home services.

Introduction : To better integrate the services with a population approach, one of the first step is to have a good knowledge of needs and unmet needs of the clientele. The continuum of services should tend to fill the gaps where unmet needs are identified both at population and individual-level. In Quebec, Canada, the standardized clinical assessments (quasi-mandatory) of persons living with physical deficiencies and receiving public services are compiled into an integrated software allowing to measure the disabilities and handicaps. In order to have a picture of the population’s unmet needs and target the development required, we conducted a descriptive analysis of the disabilities and handicap (unmet needs) of the clientele receiving public services at home. Methods : The population studied included the persons receiving at least one public service at home for physical deficiencies, during 1 year (April 2014 to March 2015). Disabilities were evaluated with the 29-item SMAF (French acronym for Functional Autonomy Measurement System) covering five sectors of activity: ADLs [7 items], mobility [6], communication [3], mental functions [5], and IADLs [8]. Each item was scored on a 5-level scale from 0 (independent) and 0.5 (with difficulty) to 3 (dependent). For each disability item, available resources to compensate for it were evaluated and a handicap score representing unmet needs was deducted. The percentage of persons having unmet needs by items is examined. Results : A total of 24 250 users were assessed during the period (81% of the total clients). The non-assessed received very few services. Disabilities (having a disability score different than zero) were more frequent in IADL disabilities (42-98% of persons for the 8 IADL), followed by mobility (23-93%) and ADL (26-87%). The unmet needs were more frequent in mobility and mental functions. The highest rates of persons with unmet needs were for the items walking inside, with 11.6%, followed by behavior (9.9%), washing (8.6%), housekeeping (8.2%), getting around outside (8.1%) and judgment (7.9%). Discussion : While the higher rates of disabilities were IADL as expected, the unmet needs were high in items related to mental functions and mobility. If the latest might appear at least “logical” with persons with physical deficiencies, the unmet needs in mental functioning tend to indicate an under-consideration of this aspect in organisation of services for the clientele. The two items related to mobility (walking inside and getting around outside) indicate high unmet needs that might affect other aspects (ex. social functioning) that could be more deeply studied in link with other component of the standardized clinical assessment. These results could help to target the different aspects of services requiring better integration, since they were not expected. A limitation of the study is the magnitude of unmet needs at individual-level by item, not captured by studying the percentage of people having unmet needs by item. The next steps will be to describe the magnitude and understand why and how the current services lead to such unmet needs in these dimensions of functioning.

The objective of this study was to explore the relationship of sociodemographic, clinical, and health-services use-related variables with transitions between disability-based profiles. In a longitudinal study of 1386 people aged 75 and over living in the community at baseline, disabilities were assessed annually for up to four years with the Functional Autonomy Measurement System (SMAF), which generates 14 Iso-SMAF profiles. These profiles are grouped into 4 disability states, which are predominant alterations in instrumental activities of daily living (IADLs), mobility, mental functions as well as severe and mixed disabilities. Continuous-time, multi-state Markov modeling was used to identify the factors associated with transitions made by older people between these states and to institutionalization and death. Greater age and receiving help for ADL were associated with four transitions, while altered cognitive functions and hospitalization were associated with three, all involving more decline or less recovery. From mild IADL profiles, men have a higher risk of transitioning to intermediate predominantly mental profiles, while women are at higher risk of transitioning to intermediate predominantly mobility profiles. Unmet needs are associated with deterioration, from mild IADL to intermediate predominantly mobility profiles. These results help understanding the complex progression of disabilities in older people.

This paper reports on the study of a subsidy programme that was established in Quebec for alternate housing models (AHMs), which allows private and community organisations to offer housing services within the framework of a partnership with public health-care services. The research objectives were: (a) to compare how facility characteristics and services provided by AHMs and nursing homes (NHs) differ; (b) to examine the personal characteristics of residents living in AHMs; and (c) to compare residents with similar characteristics within AHMs and NHs in terms of unmet needs, quality of care, satisfaction with care and services, and psycho-social adaptation to the residence. A cross-sectional study was undertaken with individually matched groups to assess whether AHMs meet the needs of elders in a way similar to NHs. Overall, residents in both groups had moderate to severe levels of disability and about 60 per cent had mild to severe cognitive problems. While their general features were heterogeneous, the AHMs were more comfortable and homelike than the NHs. The quality of and satisfaction with care was appropriate in both settings, although AHMs performed better. Only one-quarter of residents in both settings, however, evidenced a good level of psycho-social adaptation to their residence. This partnership approach is a good strategy to provide a useful range of housing types in communities that can respond to the needs of elders with moderate to severe disabilities.

BackgroundIn Europe and Asia, long-term care funding is disability-based. This introduces a perverse effect by inappropriately adding value to functional decline among beneficiaries. To support the efforts in prevention and rehabilitation made by personnel in long-term care services, indicators have to be developed to promote functional improvement of beneficiaries. As people receiving those services are already experiencing a functional decline process, it is essential to know the natural magnitude of functional decline in order to assess deviation from this expected decline. The objective of the study was to estimate the natural decrease of autonomy in beneficiaries of home care services and nursing homes.MethodsTwo databases were used: for home-dwelling people, 1235 subjects over 75years old who participated in the PRISMA study; for institutions, 1330 residents over 65years old of a nursing home in Sherbrooke (QC, Canada). These subjects were assessed several times over many years with the Functional Autonomy Measurement System (SMAF). Growth analyses were used to estimate the annual decrease in the SMAF score according to age, gender and the initial autonomy status.ResultsAt home, only age was significantly associated with the slope of functional decline. The average annual decrease of subjects 75–84years old was 2.4 points on the SMAF score (out of 87); for those aged over 85, the annual loss was 3.8 points. In institutions, gender and the initial autonomy profile were associated with the annual decrease. For men, the annual decrease varied between 0.7 for the most disabled subjects to 5.2 for the most autonomous. For women, those values varied from 0.2 to 6.6, respectively.ConclusionA decrease in the SMAF score less than these expected values should be associated with a bonus to support personnel training, prevention activities, rehabilitation and activities aimed at supporting the autonomy of the beneficiaries. Such a strategy requires the implementation of a precise and reliable assessment instrument like the SMAF and also the availability of a longitudinal database where data for each beneficiary could be linked over time.RésuméPosition du problèmeLes systèmes de financement des soins à long terme en Europe et en Asie sont basés sur les incapacités des usagers. Cela introduit un effet pervers en valorisant de façon indue la perte d’autonomie des usagers. Afin de soutenir les efforts des intervenants et des services en matière de prévention et de réadaptation, des indicateurs permettant de valoriser l’amélioration fonctionnelle doivent être développés. Comme les usagers âgés sont déjà en processus de perte d’autonomie, il est nécessaire de connaître l’évolution naturelle de l’autonomie fonctionnelle pour apprécier la déviation par rapport à cette perte attendue. L’objectif de cette étude est de déterminer la perte annuelle d’autonomie chez des usagers vivant à domicile et en institution.MéthodeDeux bases de données ont été utilisées : pour le domicile, les 1235 sujets de plus de 75ans de l’étude PRISMA ; pour l’institution, les 1330 usagers de plus de 65ans d’un centre d’hébergement de Sherbrooke (Québec, Canada). Ces sujets ont été évalués à plusieurs reprises sur une période de plusieurs années au moyen du Système de mesure de l’autonomie fonctionnelle (SMAF). Des analyses de courbes d’évolution (growth analyses) ont permis de définir la perte annuelle selon l’âge, le sexe et le profil d’autonomie initial.RésultatsÀ domicile, seul l’âge intervient dans la pente de la perte d’autonomie. La perte annuelle des personnes de 75 à 84ans peut être estimée à 2,4 points du score SMAF (sur 87) alors que celle des 85ans et plus est de 3,8 points. En institution, tant le sexe que le profil initial d’autonomie ont une influence sur la perte annuelle. Pour les hommes, elle varie de 0,7 pour les sujets les moins autonomes à 5,2 pour les personnes les plus autonomes. Pour les femmes, ces valeurs varient de 0,2 à 6,6.ConclusionUne perte inférieure à ces différences de scores devrait être associée à un bonus pour soutenir la formation du personnel, les activités de prévention et de réadaptation ainsi que des activités de soutien à l’autonomie. Une telle stratégie nécessite l’implantation dans les services d’un outil sensible et reproductible comme le SMAF, de même que la disponibilité d’une base de données dans laquelle les évaluations successives des usagers peuvent être reliées entre elles.

In Quebec, Canada, the standardized clinical assessments (quasi-mandatory) of older persons receiving public services are compiled into an integrated software. We conducted a descriptive analysis of disabilities and unmet needs in the population receiving services at home.

PRISMA is the only example of a co‐ordinated‐type model to be developed and fully implemented with a process and outcome evaluation. The PRISMA model was implemented in three areas (urban, rural with or without a local hospital) in Quebec, Canada and an implementation evaluation was carried out using mixed (qualitative and quantitative) methods. Over four years, the implementation rates went from 22% to 79%. The perception of integration by managers and clinicians working in the various organisations of the network shows that most interactions are perceived as at the co‐operation level, some getting the highest collaboration level. The perception of the efficacy of case managers was very high. Implementing such a model is feasible, and the decision to generalise it was made in Quebec. This model might be more appropriate for a universal publicly funded health care system like those in Canada, the UK and the Scandinavian countries.

Interest has grown in integrated care models as means of responding better to the needs of frail older adults. In order to provide appropriate input for health policy reforms, the effects of integrated care must be assessed with sound methodologies. Based on three experiments conducted in the province of Quebec, Canada, this article provides practical advice on key issues involved in evaluating integrated care models.

Many comprehensive rating scales have been developed to assess disabilities. These assessments, which require significant amounts of time, are usually performed by trained professionals. A simple case-finding instrument is needed to quickly identify older persons with potential disabilities, who then should undergo comprehensive assessments. In a cross-sectional study of 594 community-dwelling older subjects, we developed a questionnaire from an initial list of 23 yes/no questions, and compared it with an existing one to determine their relative ability to identify older persons with moderate to severe disabilities. Initially designed to identify older people with any disability, the existing seven-question tool also provided to be a good marker of significant disabilities, with a cut-off score of three or more positive answers. The sensitivity and specificity of this cut-off are 78.3% and 74.7%, respectively. These validity indices support the use of this questionnaire in identifying older persons with potential moderate to severe disabilities with a view to referring them for more comprehensive assessment.

OBJET: Le projet PRISMA (Programme de recherche sur l’integration des services de maintien de l’autonomie) etudie un reseau integre de services pour personne âgees (RISPA) de type coordination developpe pour ameliorer la continuite et accroitre l’efficacite et l’efficience des services. L’objectif de l’etude PRISMA est d’evaluer l’efficacite populationnelle de ce reseau a ameliorer l’autonomie, l’autonomisation et la satisfaction des personnes âgees fragiles, modifier leur utilisation des services de sante et services sociaux, et reduire le fardeau de leurs aidants. METHODOLOGIE: Une etude quasi-experimentale avec pre-test, post-tests multiples et groupe de comparaison a ete utilisee pour evaluer les impacts du RISPA. 1501 sujets âges a risque de perte d’autonomie (728 experimentaux, 773 temoins) ont participe a l’etude. RESULTATS: Les sujets du groupe experimental ont montre une reduction significative de la prevalence (6,2%) et de l’incidence (13,7%) de la perte d’autonomie avec une reduction des besoins non combles de 31%. La satisfaction et l’autonomisation se sont ameliorees. Une reduction des visites a l’urgence et des hospitalisations a aussi ete observee sans augmentation des couts des services. CONCLUSION: Le modele de coordination PRISMA est praticable et efficient dans le contexte sociosanitaire quebecois et merite d’etre adapte a d’autres contextes.

Background: While many studies investigate the factors that influence the institutionalisation of older persons, only a few consider one of its most important predictors, namely, the perceived need for institutionalisation. Also referred to as ‘desire for institutionalisation’, it has mainly been investigated for informal caregivers of older adults suffering from dementia. Not many studies target caregivers of people without dementia; even fewer have been interested in the older adult’s own perceived need. Objective: To measure the prevalence and identify the correlates of the perceived need for institutionalisation among community-dwelling older adults without cognitive impairment. Methods: During the fourth wave of the longitudinal PRISMA study, cognitive-impairment-free participants (78 years or older and at risk of functional decline) were presented with three questions assessing their perceived need for institutionalisation. Correlates were identified through multivariable logistic regression analyses. Analyses were conducted separately for two types of home living arrangements: individual and collective dwellings. Results: 27% of the older adults at least thought about institutionalisation, irrespective of their current living arrangements. For homeowners/tenants, age ranging from 80 to 85, transfer and vision problems, the absence or advanced age of the informal caregiver, and the use of the ER or help for home maintenance during the past year led them to think about institutionalisation. Seniors living in collective dwellings think about institutionalisation after experiencing a recent highly significant functional decline, when feeling that their current environment fails to meet needs, and after requiring the use of voluntary services during the past year. Conclusions: The percentage of community-dwelling older adults considering institutionalisation is the same for people currently in individual or collective settings. Factors related to physical disabilities and insufficiencies of resources are important correlates, with specific factors differing between the two types of current living arrangements.

Objective Seniors use a wide variety of health services delivered by numerous practitioners and organizations. Self-report is the most accessible and cost-effective method to collect information on their use. It is thus important to demonstrate the reliability of this approach. Study Design and Setting As part of a longitudinal study on the effect of an integrated service delivery system, participants (or their proxies) were instructed to use a calendar to record their use of health services. Every 2 months, an interviewer collected use since the last phone contact. A subsample was recontacted by the same or another interviewer to estimate test–retest and interinterviewer reliability, respectively. Data collections were compared using delta and weighted kappa as well as intraclass correlation coefficients. Results Almost perfect agreement was obtained for hospitalization, day surgery, visits to general practitioners and medical specialists, help for home maintenance, and use of voluntary services. Agreement was substantial for visits to the emergency room and home help for personal care. For visits to or by nurses and other health professionals, agreement can be qualified as moderate-to-substantial. Conclusion Assisted self-report of health-services use by older adults or their proxies through bimonthly phone calls is reliable.

Corriveau H, Hebert R, Raiche M, Prince F. Evaluation of postural stability in the elderly with stroke. Arch Phys Med Rehabil 2004;85:1095–101. Objective To compare clinical and biomechanical measures of balance in elderly stroke patients with those of healthy elderly people. Design Two-group comparison design. Setting Laboratory environment. Participants Fifteen poststroke patients and 15 healthy age-matched older adults (N=30). Interventions Not applicable. Main outcome measures The biomechanical variable COP-COM, which represents the distance between the center of pressure (COP) and the center of mass (COM) in terms of root mean square. The mean of 4 trials of the COP-COM variable for each test condition was used for statistical analysis. Furthermore, the different systems (sensory, motor, central processor) related to postural stability were evaluated. Results Statistical significance of the COP-COM variable was larger in the stroke group than in healthy subjects, in both the anteroposterior (AP) and mediolateral (ML) directions. Furthermore, statistically, stroke subjects showed amplitudes of the COP-COM variable that were significantly larger in the eyes-closed condition. The significant negative correlation demonstrated between COP-COM amplitude and the balance scales (Berg, Tinetti) indicated that the patients with larger COP-COM amplitudes had lower clinical balance score. Furthermore, correlation coefficient scores between COP-COM variables in both AP and ML directions and motor performance using Fugl-Meyer Assessment (ρ=−.53, ρ=−.51, respectively) and reaction time (ρ=−.53, ρ=−.44, respectively) were significant. Vibration (ρ=.41) and touch-pressure (ρ=.42) perception thresholds correlated significantly only in the AP direction. Conclusions Evaluating postural stability with COP-COM variable provided an accurate measure of postural stability in poststroke elderly people. Furthermore, postural stability in quiet stance, as measured by COP-COM amplitude, was related to functional measures of balance as well as physiologic factors relating to balance, such as visual conditions, lower-extremity peripheral sensibility, motor recovery, and simple reaction time.

Services to older persons have developed considerably and become highly specialized in recent decades, but they are also highly fragmented. Both in France and Québec, various attempts at coordination have been made in order to improve the continuity of services. The aim of this article is to highlight the common and different aspects of service coordination by examining: the observations and challenges related to service coordination, past and current experiences of coordination, the research teams who assess these experiences as well as the research fields they explored in order to assess the implementation and impact of these experiences on older clienteles. Lastly, a few discussion points and research avenues are suggested for future studies., Les services aux personnes âgées se sont fortement développés et spécialisés au cours des dernières décennies, mais avec un fractionnement marqué. En France comme au Québec, des expériences de coordination des services ont vu le jour afin d’améliorer la continuité de ces services. Cet article vise à faire ressortir les points communs et les différences qui émergent face aux constats et enjeux de la coordination des services, les différentes expériences de coordination passées et en cours, les équipes de recherche qui oeuvrent à évaluer ces expériences ainsi que les champs de recherche qu’elles ont explorés afin d’en évaluer l’implantation et l’impact sur les clientèles âgées. Enfin, nous soulèverons quelques points de discussion et quelques pistes sur lesquelles porteront les travaux futurs., Raîche Michel, Hébert Réjean. La coordination des services aux personnes âgées en France et au Québec : enjeux, expériences et champs de recherche traitant de leur évaluation. In: Santé, Société et Solidarité, n°2, 2003. Vieillissement et santé II. pp. 57-66.

Although the identification and characterization of limb load asymmetries during quiet standing has not received much research attention, they may greatly extend our understanding of the upright stance stability control. It seems that the limb load asymmetry factor may serve as a veridical measure of postural stability and thus it can be used for early diagnostic of the age-related decline in balance control. The effects of ageing and of vision on limb load asymmetry (LLA) during quiet stance were studied in 43 healthy subjects (22 elderly, mean age 72.3+/-4.0 yr, and 21 young, mean age 23.9+/-4.8 yr). Postural sway and body weight distribution were recorded while the subject was standing on two adjacent force platforms during two 120 s trials: one trial was performed with the eyes open (EO), while the other trial was with the eyes closed (EC). The results indicate that LLA was greater in the old adults when compared with the young control subjects. The LLA values were correlated with the postural sway magnitudes especially in the anteroposterior direction. Eyes closure which destabilized posture resulted in a significant increase of body weight distribution asymmetry in the elderly but not in the young persons. The limb load difference between EO and EC conditions showed a significantly greater effect of vision on LLA in the elderly compared to the young subjects. The observed differences in the LLA may be attributed to the decline of postural stability control in the elderly. Ageing results in the progressive decline of postural control and usually the nervous system requires more time to complete a balance recovery action. To compensate for such a deficiency, different compensatory strategies are developed. One of them, as evidenced in our study, is preparatory limb unload strategy (a stance asymmetry strategy) which could significantly shorten reaction time in balance recovery.

The objectives of this study were to standardize measurement procedures and study the test-retest and interrater reliability of the belt-resisted method for measuring the lower extremity isometric strength of three muscle groups. The strength of 33 healthy, elderly, community-dwelling subjects was evaluated with a hand-held dynamometer using the belt-resisted method. Isometric strength testing of three muscle groups (hip flexors, knee extensors, and ankle dorsiflexors) was performed on two separate occasions, I week apart, by the same tester to determine test-retest reliability. The test results of two different examiners testing on different days were used to determine interrater reliability. Test-retest reliability was higher than interrater reliability. Test-retest reliability coefficients of the three muscle groups were high (J9-.95). For interrater reliability, intraclass correlation coefficients varied from .64 to .92. depending on the muscle group and side. For the two kinds of reliability, intraclass correlation coefficients increased from proximal to distal. The method for the hip muscle group should be modified to increase reliability of the measure.

The objective of this study is to use Iso-SMAF functional autonomy profiles (SMAF: French acronym for Functional autonomy measurement system) and other clinical and sociodemographic characteristics to develop algorithms that would support decision-making in orienting disabled people that would be adapted to current and future options available to a healthcare system in the Canton of Geneva.A modified Delphi expert consultation, including the RAND/UCLA method, was used. After two rounds of consultations in which the experts responded to Web-based questionnaires, a nominal group completed the study.A total of 108 experts took part in the online consultation during the two rounds of consultation; 13 took part in the nominal group. In addition to belonging to various disciplines, the participants came from the different care structures within the Canton of Geneva. The findings made it possible to develop 14 decision-making algorithms, eight of which received consensus support in the first round of consultation. The second round and nominal group achieved consensus for others. The profiles with moderate to severe cognitive impairment were those for which the orientation options required several rounds of voting.Since the orientation choices suggested by the algorithms were relatively standardized, they constitute recommendations that can guide professionals in orienting people.

Introduction: The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow up frail and disabled community-dwelling older people.Theory and method: A rigorous process was applied according to a series of steps: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team.Results: ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans.Conclusion: Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

Background The PRISMA Model is an innovative coordination-type integrated-service-delivery (ISD) network designed to manage and better match resources to the complex and evolving needs of elders. The goal of this study was to examine the impact of this ISD network on unmet needs among disabled older persons living in the community. Methods Using data from the PRISMA study, we compared unmet needs of elders living in the community in areas with or without an ISD network. Disabilities and unmet needs were assessed with the Functional Autonomy Measurement System (SMAF). We used growth-curve analysis to examine changes in unmet needs over time and the variables associated with initial status and change. Sociodemographic characteristics, level of disability, self-perceived health status, cognitive functioning, level of empowerment, and the hours of care received were investigated as covariates. Lastly, we report the prevalence of needs and unmet needs for 29 activities in both areas at the end of the study. Results On average, participants were 83 years old; 62% were women. They had a moderate level of disability and mild cognitive problems. On average, they received 2.07 hours/day (SD = 1.08) of disability-related care, mostly provided by family. The findings from growth-curve analysis suggest that elders living in the area where ISD was implemented and those with higher levels of disability experience better fulfillment of their needs over time. Besides the area, being a woman, living alone, having a higher level of disability, more cognitive impairments, and a lower level of empowerment were linked to initial unmet needs (r2 = 0.25; p < 0.001). At the end of the study, 35% (95% CI: 31% to 40%) of elders with needs living in the ISD area had at least one unmet need, compared to 67% (95% CI: 62% to 71%) in the other area. In general, unmet needs were highest for bathing, grooming, urinary incontinence, walking outside, seeing, hearing, preparing meals, and taking medications. Conclusions In spite of more than 30 years of home-care services in the province of Quebec, disabled older adults living in the community still have unmet needs. ISD networks such as the PRISMA Model, however, appear to offer an effective response to the long-term-care needs of the elderly.

Purpose Planning home services for older people requires extensive knowledge about the progression of disabilities. Disability-based case-mix classifications identify meaningful groups of older people; yet transitions between profiles are mostly unknown. Methods Disability was assessed annually over four years with the Functional Autonomy Measurement System (SMAF) in 1410 older people at risk of functional decline aged 75 and over and living at home. The SMAF generates a case-mix classification of 14 Iso-SMAF profiles with progressive mean disability levels. Transitions made by older people were analyzed using a continuous-time, multi-state Markov model to estimate the probabilities of annual transitions into and out of each profile as well as the mean sojourn time in each profile. Results The probability of staying in a profile tended to decrease as profile severity increased. For profiles 5 and above, recovery to mild profiles 1, 2 and 3 was low, while annual probabilities of death and institutionalization were high (>0.10). The lower disability profiles (1 and 2) evidenced a mean profile sojourn time of over two years, contrary to sojourn times of 18 months or less with the other profiles. Conclusions The probabilities are identifiable, indicating that a disability-based classification can characterize progression in older people. Since the required resources and costs are known for each profile, these probabilities are very helpful in planning home services for elderly populations.

Policy-makers and health care managers need accurate information on disabilities in the population to plan appropriate services to the older population. Disability information from population surveys are often very crude as compared to information used on the clinical field. This study aimed to verify the concurrent validity of a survey questionnaire version of a disability instrument (SMAF) administered by lay interviewers, compared to the original SMAF rating scale completed by clinicians.The survey questionnaire version was developed by a panel of experts and pretested with 15 patients attending a day hospital program using a think-aloud approach. A social worker administered the SMAF rating scale at home to a sample of Community-dwelling frail people over 81 years old who participated in the PRISMA longitudinal study in Sherbrooke, Québec, Canada. The same subjects were contacted one month later by a lay interviewer, who completed the survey questionnaire. The two versions were compared using intraclass correlation coefficients (ICCs) and weighted kappas (WK).96 subjects participated in the study. The ICC was 0.82 for the total SMAF score and ranged from 0.46 (mental functions) to 0.82 (IADL) for the subscores. The questionnaire version systematically underestimated disability by 4.7 points on average (out of 87) (p0.0001). For the case-mix classification generated from the disability assessment (Iso-SMAF profiles), the underestimation was even more striking.A survey questionnaire is not a valid method for accurately estimating disability in a population.

Introduction: The PRISMA-7 tool [1] has been introduced in two emergency rooms (ERs) in Sherbrooke to identify older people with significant disabilities. The seven yes/no questions had been included in the triage instrument for people aged 75 years and over. The positive cases were directed to the single entry point of the local health and social services centre, which then conducted assessment and eventually provided home care. The study’s objective was to monitor the rate of PRISMA-7 use in ERs since its implementation (4 years ago). Results: During the first year of implementation, the rate of PRISMA-7 use gradually increased up to 50–60%, then remained stable during the second and third years. This plateau can be accounted for, in part, by the scarcity of resources for assessing and delivering home-care services. The rate of PRISMA-7 use fell to 40% during the fourth year, which coincided with renovation of an ER. A 50% objective is in place. Discussion: The rate of case-finding appears logical with the services actually available for assessing functional autonomy and the cor responding home services required. In terms of the population-health approach for supporting functional autonomy, it highlights the challenges in reaching the population level. As suggested by Young and Turnock [2], some managers consider publishing community-care waiting lists to increase attention and, consequently, priority in the health system.

Introduction: Under the PRISMA coordination model, all older people benefit from several model components, but only subjects identified with moderate to severe disabilities are eligible for case management. The PRISMA model has proven its effectiveness at the population level. However, for the sub-group with case management, what is its effect on services use? Study: We used data from the PRISMA study on adults aged 75 or over at risk of functional decline to compare subjects exposed to case management to unexposed ones, matched for functional disabilities, age, and gender. We studied change in annual services use, contrasting the year of assignment to the previous year. Results: Among subjects in the PRISMA experimental group, 18% were assigned a case manager. Matched pairs were created for 49 cases for which data were available before and after assignment. Change in the number of annual ER visits was similar across groups, but the number of annual hospitalisations tended to increase less for exposed subjects (p=0.08). Change in annual hours for home maintenance was similar across groups, but more hours of help for personal care were added for case-managed older people (p=0.01), possibly by increasing access to home care. This strengthens the value of case management in an ISD network.

We aimed to compare behaviour towards institutionalisation between frail older adults and their informal caregivers, and identify correlates of differential behaviour. In 2004, during the fourth wave of the longitudinal Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) study (province of Quebec, Canada), 86.7% of eligible dyads, that is 593 participants and their primary informal caregivers, were asked separately if they thought about placement, discussed it with someone or visited an institution during the previous year. An ordinal measure of behaviour towards institutional placement was derived and agreement between dyad members was assessed with the weighted kappa. Although identical behaviour was relatively high (65.4%), it represented almost exclusively no thoughts by either member and the weighted kappa was low (0.16). Differential behaviour was then analysed as a three-level dependent variable (thoughts only by the care-receiver, thoughts only by the caregiver, no thoughts by either dyad member) in a multiple multinomial logistic regression analysis. Compared with neither person thinking about it, the care-receiver alone thinking about placement was associated with using voluntary services, receiving help for home maintenance and visits to the emergency room during the previous year, along with the caregiver being aged 70 years or over. Compared with neither person thinking about it, the caregiver alone thinking about placement was associated with being male, not residing with the care-receiver, sensing a higher subjective burden, along with the care-receiver being 85 years or older, not being able to feed him/herself independently and visits to the emergency room during the previous year. Identified correlates can be useful in targeting dyads likely to behave differently. Communication within these dyads needs to be enhanced, as it is crucial to ensure that both parties are comfortable with possible future institutionalisation. In this regard, health professionals could play a role in bringing the issue to discussion.

Objectives . To evaluate the impact of a coordination-type integrated service delivery (ISD) model on health, satisfaction, empowerment, and services utilization of frail older people. Methods . Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is a populationbased, quasi-experimental study with three experimental and three comparison areas. From a random selection of people 75 years or older, 1,501 persons identifi ed at risk of functional decline were recruited (728 experimental and 773 comparison). Participants were measured over 4 years for disabilities (Functional Autonomy Measurement System), unmet needs, satisfaction with services, and empowerment. Information on utilization of health and social services was collected by bimonthly telephone questionnaires. Results . Over the last 2 years (when the implementation rate was over 70%), there were 62 fewer cases of functional decline per 1,000 individuals in the experimental group. In the fourth year of the study, the annual incidence of functional decline was lower by 137 cases per 1,000 in the experimental group, whereas the prevalence of unmet needs in the comparison region was nearly double the prevalence observed in the experimental region. Satisfaction and empowerment were signifi cantly higher in the experimental group. For health services utilization, a lower number of visits to emergency rooms and hospitalizations than expected was observed in the experimental cohort. Conclusion . The PRISMA model improves the effi cacy of the health care system for frail older people.

Purpose: The PRISMA study analyzes an innovative coordination-type integrated service delivery (ISD) system developed to improve continuity and increase the effectiveness and efficiency of services, especially for older and disabled populations. The objective of the PRISMA study is to evaluate the effectiveness of this system to improve health, empowerment and satisfaction of frail older people, modify their health and social services utilization, without increasing the burden of informal caregivers. The objective of this paper is to present the methodology and give baseline data on the study participants. Methods: A quasi-experimental study with pre-test, multiple post-tests, and a comparison group was used to evaluate the impact of PRISMA ISD. Elders at risk of functional decline (501 experimental, 419 control) participated in the study. Results: At entry, the two groups were comparable for most variables. Over the first year, when the implementation rate was low (32%), participants from the control group used fewer services than those from the experimental group. After the first year, no significant statistical difference was observed for functional decline and changes in the other outcome variables. Conclusion: This first year must be considered a baseline year, showing the situation without significant implementation of PRISMA ISD systems. Results for the following years will have to be examined with consideration of these baseline results.

The study investigated whether physiological factors related to specific body systems can explain postural control as measured by the scalar distance at a given time between the center of pressure (COP) and the center of mass (COM), the COP-COM variable. The data from 46 healthy subjects and 29 subjects with disabilities due to stroke or diabetic peripheral neuropathy were analyzed. The biomechanical variable COP-COM was determined using two force platforms and an optoelectric system. Three systems were considered as possible predictors of the COP-COM amplitude: sensory (somatosensory and vision), musculoskeletal and central processor. A confirmatory analysis was done using structural equation modeling. Strength explained 23.74% of the COP-COM amplitude in the antero-posterior (A/P) with eyes open (EO) condition, and in the medio-lateral (M/L) direction strength explained 40.73 and 28.75% in the EO and eyes closed (EC) respectively. In the A/P direction with EC, 51.75% of the COP-COM amplitude variance was explained mainly by the somatosensory system. This study highlight the role of peripheral somatosensory input and muscle strength in the maintenance of postural stability during quiet stance in the elderly. The indirect action of the different systems on the COP-COM amplitude supports the systems theory.

Corriveau H, Hebert R, Prince F, Raiche M. Postural control in the elderly: an analysis of test-retest and interrater reliability of the COP-COM variable. Arch Phys Med Rehabil 2001;82:80-5. Objectives: To estimate the test-retest and interrater reliability of the center of pressure-center of mass (COP-COM) variable of postural control in the elderly. Design: The biomechanic variable COP-COM, which represents the distance between the COP and the COM, was determined from 2 AMTI force platforms and 3 OPTOTRAK® position sensors. Measurements were taken in quiet position, double leg stance, and eyes open and eyes closed conditions. Setting: Laboratory environment. Participants: Forty-five healthy subjects, 8 patients with diabetes neuropathy, and 7 stroke survivors, all of whom were at least 60 years old. Interventions: Subjects were evaluated on 2 separate occasions within 7 days by the same evaluator to determine test-retest reliability. Interrater reliability was determined the same day. Main Outcome Measures: The biomechanic variable COP-COM, which represents the distance between the COP and the COM in terms of root mean square. The mean of 4 trials of the COP-COM variable for each condition was used for statistical analysis. Intraclass correlation coefficients (ICCs) were used. Results: The COP-COM variable has good reliability for both the test-retest and interrater studies, but its reliability varies according to the direction of the COP-COM. For the test-retest and interrater studies, the ICC ranged from.89 to.93 in the anteroposterior direction and from.74 to.79 in the mediolateral direction. Conclusion: The equivalence of the test-retest and interrater coefficients obtained suggests that the measurement error of the COP-COM variable is mainly linked to the biologic variability of this measure over a short period of time. Using the mean of 4 trials stabilizes the COP-COM variable enough to be potentially used to evaluate clinical change. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

In a prospective study of 225 community dwelling people 75 years and older, we tested the validity of the Tinetti balance scale to predict individuals who will fall at least once during the following year. A score of 36 or less identified 7 of 10 fallers with 70% sensitivity and 52% specificity. With this cut-off score, 53% of the individuals were screened positive and presented a two-fold risk of falling. These characteristics support the use of this test to screen older people at risk of falling in order to include them in a preventive intervention.

OBJECTIVE: The objective of this study was to compare clinical and biomechanical characteristics of balance in diabetic polyneuropathic elderly patients and normal age-matched subjects. RESEARCH DESIGN AND METHODS: Fifteen elderly with distal neuropathy (DNP) and 15 healthy age-matched subjects were evaluated with the biomechanical variable COP-COM, which represents the distance between the center of pressure (COP) and the center of mass (COM). Measurements were taken in the quiet position with a double-leg stance, in eyes-open (EO) and eyes-closed (EC) conditions. Subjects were also assessed with clinical balance evaluations. RESULTS: The COP-COM variable was statistically significantly larger in the DNP group than in the healthy group in anterior-posterior (A/P) and medial-lateral (M/L) directions. Furthermore, the DNP group showed statistically significantly larger amplitudes of the COP-COM variable without vision. The severity of the neuropathy, as quantified using the Valk scoring system, was correlated with COP-COM amplitude in both directions. CONCLUSIONS: Evaluation of the postural stability of an elderly diabetic population using the COP-COM variable can detect a very small change in postural stability and could be helpful in identifying elderly with DNP at risk of falling.

Corriveau H, Hebert R, Prince F, Raiche M. Intrasession reliability of the "center of pressure minus center of mass" variable of postural control in the healthy elderly. Arch Phys Med Rehabil 2000;81:45-8. Objectives: To estimate the intrasession reliability of a single measure of the biomechanical variable "center of pressure minus center of mass" (COP-COM) to determine, first, how many trials must be averaged to obtain a reliable measure of postural stability, and second, the minimal metrically detectable change of the COP-COM. Participants: Community-living, healthy, elderly people over 60 years of age ( n = 7). Design: Measurements were made in double leg stance, eyes-open condition. Nine successive trials, with rests between, were carried out for each subject. Data Analysis: Intraclass correlation coefficients (ICCs). Main Outcome Measure: The biomechanical variable COP-COM, which represents the distance between the center of pressure and the center of mass, was measured from two force platforms and three position sensors. Results: The ICCs obtained for one measure of the COP-COM were .79 in the anterior-posterior (AP) direction and .69 in mediolateral (ML) direction. With four trials, the COP-COM variable is reliable at .94 in the AP direction and .90 in the ML direction. Minimal metrically detectable changes were .10mm (AP) and .16mm (ML). Conclusion: Using four repetitions of the COP-COM variable provides a reliable measurement of postural stability. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objectif : l’objectif de cette etude est d’elaborer, sur la base des profils d’autonomie fonctionnelle Iso-SMAF (SMAF : Systeme de mesure de l’autonomie fonctionnelle) et d’autres caracteristiques cliniques et socio-demographiques, des algorithmes en soutien a la decision d’orientation des personnes en perte d’autonomie, adaptes aux options actuelles et futures d’un reseau de soins dans le canton de Geneve.Methodes : une consultation d’experts de type Delphi modifie incluant la methode de RAND/UCLA a ete utilisee. Apres deux tours de consultation dans lesquels les experts repondaient a des questionnaires par le biais d’Internet, un groupe nominal a complete l’etude.Resultats : au total, 108 experts ont participe a la consultation en ligne lors de deux tours de consultation, et 13 au groupe nominal. En plus d’appartenir a des disciplines diverses, les participants provenaient des differentes structures de soins du canton de Geneve. Les resultats obtenus ont permis de developper 14 algorithmes d’aide a la decision, dont huit ont fait consensus lors du premier tour de l’etape du Delphi. Le deuxieme tour et le groupe nominal ont permis l’atteinte de consensus pour les autres. Les profils avec atteinte cognitive moderee a grave sont ceux ou les options d’orientations ont fait l’objet de plusieurs tours de vote.Conclusion : les choix d’orientation suggeres par les algorithmes etant relativement standardises, ils constituent des recommandations permettant de guider les professionnels lorsqu’ils entreprennent une demarche d’orientation pour un usager.

De nombreuses decisions d'ordre methodologique doivent etre prises lors de la construction d'un cadre d'evaluation des effets d'un reseau integre de services gerontologiques. Le present article vise a guider cette prise de decisions par une comparaison des parametres methodologiques de trois evaluations de reseau integre realisees au Quebec : le projet des Bois-Francs, PRISMA et SIPA. Nous debutons avec la presentation d'un cadre theorique que le Conseil de recherche medicale du Royaume-Uni a propose dans le but de soutenir le developpement et l'evaluation d'interventions complexes. Nous abordons ensuite trois facteurs qui exercent, selon nous, une influence marquee sur le choix du devis de recherche, puis traitons des autres elements cles du cadre d'evaluation que sont la population et l'echantillon, les hypotheses et mesures d'impact, l'effectif et le plan d'analyse statistique. Nous concluons avec une vue d'ensemble des divers elements du cadre d'evaluation et de leurs influences mutuelles.