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SIPA Demonstration Project: implementation
and assessment
Implementation
The SIPA demonstration project, based on the previously described
model, was a community program that assumed clinical and administrative
responsibility for all services required by frail elderly participants.
The clinical aspect of this demonstration project was organized
around a multidisciplinary team and case manager. The service plan,
as well as its execution and follow-up, were the responsibility
of this team and the individuals associated with it. Lastly, the
demonstration project operated within the context of Canadian and
Quebec health-related legislation. Through the addition of a significant
number of community resources, case management, a team structure
for care delivery, clinical responsibility for all care, and cooperation
between institutions, this project represented a major operational
change within the Quebec health and social service system. However,
its orientations and operational methods were consistent with the
orientations of this system’s current efforts at reform.
The demonstration project took place at two CLSC sites located
in Montreal, i.e., the CLSC Côte-des-Neiges and the CLSC Bordeaux-Cartierville.
The project differed from the model in that it did not assume financial
responsibility for the short- and long-term care and services utilized
by the elderly persons admitted to it.
Assessment
The demonstration project was evaluated by the RRSSSM-C at the SOLIDAGE
Université de Montréal—McGill University Research
Group on Integrated Services for Older Persons.
The assessment was intended to allow researchers to examine the
ability of the demonstration project to apply the SIPA clinical
and organizational models, alter the configuration of care and services,
monitor costs, and guarantee quality of care. In other words, the
purpose of the demonstration project and assessment was to examine
whether or not SIPA, in comparison to the current system, was able
to meet the needs of vulnerable older persons through appropriate,
high-quality care and services, as a cost equal to the services
currently available to this population.
The objectives of the SIPA demonstration project assessment were:
1) to examine the ability to establish and organize services according
to the SIPA model;
2) to evaluate the quality of care and services provided;
3) to examine the ability of the SIPA project to meet the needs
of frail elderly persons and verify its impact on their state of
health;
4) to make sure that patterns of service utilization were consistent
with the SIPA model; and
5) to obtain a cost estimate and compare the costs of services provided
to those in the SIPA group to those associated with services provided
to a comparable group of older persons.
The examination of various aspects of this assessment was subject
to a multifaceted methodological process, in which various study
designs, and several observational and data analysis procedures
were used. Several types of data were required, including data on
the establishment and organization of SIPA, quality of care, the
health of the older persons and caregivers participating, their
patterns of health and social service use, and the costs of services.
Eligibility Criteria
The older persons recruited for the demonstration project were
selected from among the patients, aged 65 or over, registered
for home support services with the CLSC Côte-des-Neiges
and the CLSC Bordeaux-Cartierville. The older persons were recruited
by the clinical personnel working for the CLSC home support
services department, for an evaluation of their functional ability
according to the SMAF instrument (Hébert
et al., 1988). This instrument is part of the multi-clientele form
used by CLSCs in the Montreal area to determine the overall
needs of patients admitted to the home support services program.
Those with a SMAF score of 10 or higher were asked to participate
in the study. Those who did not meet this criterion were excluded.
Research Design
Case study: The case study method was the research strategy chosen
to analyse the influence of the organizational and interorganizational
context on the degree of implementation of SIPA (Yin, 1989). Each
experimental site constituted one analytical unit that was followed
longitudinally in order to understand the dynamics of implementation
(Patton, 1990).
Experimental design: An experimental protocol (randomized clinical
trial) was used to evaluate service utilization and costs, as well
as the state of health of the older persons and caregivers participating
in the study. A total of 1230 frail older persons were recruited.
These individuals were randomly assigned to either the experimental
group (to receive care according to the SIPA model) or the control
group (to receive the usual care offered by the CLSC).
Consent
Consent to participate in the study included an agreement regarding
random assignment to either the experimental or control group; participation
in interviews with open- or closed-ended questions; and agreement
to allow examination of their social service, medical and hospital
records and MED-ECHO administrative files kept by the Quebec Ministry
of Health and Social Services and the Régie de l’assurance
maladie du Québec (RAMQ). Participant’s RAMQ identification
numbers were requested.
Recruitment
The recruitment process was carried out from January to August 1999.
Participants were randomly assigned either to the experimental or
control group. Individuals were excluded from the demonstration
project if they were planning to move out of the CLSC territories
within the following six months; waiting to be placed in a chronic
care institution; researchers were unable to obtain consent from
a caregiver on behalf of a person unable to provide enlightened
consent; or the principal caregiver refused to participate. One
individual in the eligible subject’s home had to understand
either French or English.
Data collection
Various collection procedures were utilized: direct observation,
case study, semi-structured interviews, regular interviews, closed-ended
questionnaires, and examination of social service, medical or hospital
records and administrative files. The establishment and organization
of SIPA was examined via observation and open-ended interviews.
Quality of care was analysed via qualitative and quantitative observation.
Data on state of health, socio-economic status, assistance received,
some of the care and services received, private costs for home support
services, and caregiver burden were collected via closed-end questionnaires.
Data on patterns of use and costs of services were obtained via
examination of institutional social service, medical and hospital
records, and computer files kept by institutions, the Regional Health
Board and the Ministry of Health and Social Services.
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