title: Frail elderly patients. New model for integrated service delivery.
abstract: OBJECTIVE
  Given the complex needs of frail older people and the multiplicity of care providers and services, care for this clientele lacks continuity.
  
  
  OBJECTIVE
  Integrated service delivery (ISD) systems have been developed to improve continuity and increase the efficacy and efficiency of services.
  
  
  METHODS
  The Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is an innovative ISD model based on coordination. It includes coordination between decision makers and managers of different organizations and services; a single entry point; a case-management process; individualized service plans; a single assessment instrument based on clients' functional autonomy, coupled with a case-mix classification system; and a computerized clinical chart for communicating between institutions and professionals for client monitoring.
  
  
  CONCLUSIONS
  Preliminary results on the efficacy of this model showed a decreased incidence of functional decline, a decreased burden for caregivers, and a smaller proportion of older people wishing to enter institutions.
authors.affiliation: Research Centre on Aging, Sherbrooke, QC. Rejean.hebert@usherbrooke.ca
authors.forename: Rejean
authors.initials: R
authors.lastname: Hébert
authors.forename: Pierre J
authors.initials: PJ
authors.lastname: Durand
authors.forename: Nicole
authors.initials: N
authors.lastname: Dubuc
authors.forename: André
authors.initials: A
authors.lastname: Tourigny
mesh_terms: D000368:Aged; D002170:Canada; D019090:Case Management / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004185:Disability Evaluation; D015577:Geriatric Assessment; D006297:Health Services Accessibility / Q000458:organization & administration; D006299:Health Services for the Aged / Q000458:organization & administration*; D006801:Humans; D017146:Models, Organizational; D011357:Product Line Management; D015397:Program Evaluation