Seniors in need, caregivers in distress:

44 Health Council of Canada
PROMISING PRACTICE *
PRISMA Integrative Health Service
Program
In 2006, about 14% of Quebec’s population was
over age 65, 81 and more than three-quarters (77%)
of seniors had at least one select chronic condition. 82
A model of integrated care called the Program of
Research to Integrate Services for the Maintenance
of Autonomy (PRISMA) was developed to address
many of the challenges of delivering comprehensive
health care services to an aging population. Seniors
who are eligible for services are over age 65, have
moderate to severe disabilities, show potential for
staying at home, and need two or more services. 83
The PRISMA model is based on six key elements: 84
• Coordination of organizations and services
Coordination first occurs at the governance level
to bring together health care and social services,
then at the management level to coordinate services,
and finally at the operational level to bring together
an interdisciplinary team.
• A single point of entry This provides a portal for
people to access all the services they need through
a single source, rather than expecting them to seek
out services from multiple sectors and providers
to meet their needs.
• Case management Case managers provide an initial
assessment and are involved with planning and
coordination of services with the patient and family.
They also act as patient advocates.
• An individualized service plan This plan is based on
the assessment and is developed by the case
manager in discussion with the multidisciplinary team,
as well as with the client and caregiver.
• A standardized assessment To evaluate clients’
needs and determine the right package of services, a
standardized assessment tool (the Functional Autonomy
Measurement System, known by its French acronym
as SMAF) is used to measure functional independence,
communication, and mental functions. This tool is being
used in several regions of Quebec to inform financing
of long-term care facilities and home care services.
• Electronic records A computerized clinical chart
provides an electronic record that enables
communication between the health care team as
well as between organizations.
The PRISMA group conducted a four-year study
to evaluate the impact of the model on the ability
of seniors to remain in their homes. The study found
fewer people in the PRISMA program experienced
functional decline compared to seniors not in the
program, and there were fewer admissions to emergency
departments. Satisfaction and empowerment levels
were higher among the PRISMA participants compared
84, 85
to seniors not participating in the program.
Since 2005, Quebec’s Ministry of Health and Social
Services generalized the PRISMA model across
the province by merging all public hospitals, long-term
care facilities, and home care agencies under single
organizations within a region, organized into 95 health
and social service centres across the province.
The next step in implementation involves functional
integration within the merged structures. The PRISMA
model has been expanded to other regions in Quebec,
and a pilot project has been initiated in France. The
PRISMA group is working closely with policy-makers
86, 87
towards a more integrated system in Quebec.
* The Health Council of Canada has established criteria to
categorize innovative practices as emerging, promising, or leading
(www.healthcouncilcanada.ca/innovativepractices)