title: Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people.
abstract: BACKGROUND
  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.
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, and Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada.
authors.forename: Nicole
authors.initials: N
authors.lastname: Dubuc
authors.forename: Lucie
authors.initials: L
authors.lastname: Bonin
authors.forename: André
authors.initials: A
authors.lastname: Tourigny
authors.forename: Luc
authors.initials: L
authors.lastname: Mathieu
authors.forename: Yves
authors.initials: Y
authors.lastname: Couturier
authors.forename: Michel
authors.initials: M
authors.lastname: Tousignant
authors.forename: Cinthia
authors.initials: C
authors.lastname: Corbin
authors.forename: Nathalie
authors.initials: N
authors.lastname: Delli-Colli
authors.forename: Michel
authors.initials: M
authors.lastname: Raîche
keywords: client-centered; disability; frailty; home care; integrated care pathways; older people