Adapting the Quebecois method for assessing implementation to the French National Alzheimer Plan 2008-2012: lessons for gerontological services integration.

INTRODUCTION: Many countries face ageing-related demographic and epidemiological challenges, notably neurodegenerative disorders, due to the multiple care services they require, thereby pleading for a more integrated system of care. The integrated Quebecois method issued from the Programme of Research to Integrate Services for the Maintenance of Autonomy inspired a French pilot experiment and the National Alzheimer Plan 2008-2012. Programme of Research to Integrate Services for the Maintenance of Autonomy method implementation was rated with an evaluation grid adapted to assess its successive degrees of completion. DISCUSSION: The approaching end of the president's term led to the method's institutionalization (2011-2012), before the implementation study ended. When the government changed, the study was interrupted. The results extracted from that 'lost' study (presented herein) have, nonetheless, 'found' some key lessons. KEY LESSONS/CONCLUSION: It was possible to implement a Quebecois integrated-care method in France. We describe the lessons and pitfalls encountered in adapting this evaluation tool. This process is necessarily multidisciplinary and requires a test phase. A simple tool for quantitative assessment of integration was obtained. The first assessment of the tool was unsatisfactory but requires further studies. In the meantime, we recommend using mixed methodologies to assess the services integration level.

[The French Society of Geriatrics and Gerontology position paper on the concept of integration. Part two]. / Prise de position de la Société française de gériatrie et gérontologie sur le concept d'intégration : texte intégral Deuxième partie.

The concept of integrated services delivery, although dating from the 1990s, has only recently appeared in French public health policy. To clarify the concept and its adaptation to the reality of the French systems of healthcare and social services, the French Society of Geriatrics and Gerontology established an interdisciplinary working group. This article reports that group's findings according to three axes: the definition of integration, the objectives of this organizational approach and the means needed to achieve them. Analysis of the literature indicated that integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, finance, interventions and returns on the latter. Indeed, this sharing is the ultimate proof of evolution towards integration. In the second part of the position paper, its authors have developed arguments that could lead professionals and non-professional caregivers to adopt integrated care as an answer to their aspirations. Policy-maker perspectives and politicians are also analyzed. Bearing in mind that integrated care necessarily will always involve a human component which may find expression during individual case-management; relations between integration and case managements are clarified. Finally, lessons learned from national and international experiments are examined. Results suggest that integrated care must to be accompanied by a local pilot. Results of recent experiments have shown that it is possible to initiate a dynamic towards integrated care in France and hence join the international movement towards adapting our healthcare systems to new challenges.

The French Society of Geriatrics and Gerontology position paper on the concept of integration.

INTRODUCTION: The concept of integration, although dating from the 1990s, has only recently appeared in French public health policy. It must be linked with 'coordination', which is the base of most French public policies applied to geriatrics since the 1960s. Herein, we report the French Society of Geriatrics and Gerontology working group's findings according to three axes: definition of integration, objectives of this organisational approach and the means needed to achieve them. DISCUSSION: Integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, financing, interventions and action-reports on the latter. Integration must be accompanied by a local dedicated professional (the 'pilot'). Results of recent experiments showed that it is possible to implement integrative dynamics in France.

Multidisciplinary teams of case managers in the implementation of an innovative integrated services delivery for the elderly in France.

BACKGROUND: The case management process is now well defined, and teams of case managers have been implemented in integrated services delivery. However, little is known about the role played by the team of case managers and the value in having multidisciplinary case management teams. The objectives were to develop a fuller understanding of the role played by the case manager team and identify the value of inter-professional collaboration in multidisciplinary teams during the implementation of an innovative integrated service in France. METHODS: We conducted a qualitative study with focus groups comprising 14 multidisciplinary teams for a total of 59 case managers, six months after their recruitment to the MAIA program (Maison Autonomie Integration Alzheimer). RESULTS: Most of the case managers saw themselves as being part of a team of case managers (91.5%). Case management teams help case managers develop a comprehensive understanding of the integration concept, meet the complex needs of elderly people and change their professional practices. Multidisciplinary case management teams add value by helping case managers move from theory to practice, by encouraging them develop a comprehensive clinical vision, and by initiating the interdisciplinary approach. CONCLUSIONS: The multidisciplinary team of case managers is central to the implementation of case management and helps case managers develop their new role and a core inter-professional competency.

[The French Society of Geriatrics and Gerontology position paper on the concept of integration, Part One]. / Prise de position de la Société française de gériatrie et gérontologie sur le concept d'intégration : texte intégral Première partie.

The concept of integrated services delivery, although dating from the 1990s, has only recently appeared in the French public health policy. To clarify the concept and its adaptation to the reality of the French systems of healthcare and social services, the French Society of Geriatrics and Gerontology established an interdisciplinary working group. This article reports the group's findings according to three axes: the definition of integration, the objectives of this organizational approach and the means needed to achieve them. Analysis of the literature indicated that integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, finance, interventions and feed-back on the latter. Indeed, this sharing is the ultimate proof of evolution towards integration. In this first part of the position paper, its authors analyzed integrated care definitions used in international literature in view of designing the most important components of integrated care. The examination of this concept must be articulated with the idea of "coordination" which has been the cornerstone of the majority of public policies applied to the field of geriatrics and gerontology since the 1960s in France. The components of integrated care highlight that it is an ambitious process leading to real systemic modification. The authors also have proposed to open up a dialogue between citizens' aspirations and integrated care objectives with the aim to verify that the latter respond to the needs as expressed by the targeted group.

Exploring representations and experiences of case-management users: towards difficulties and solutions to leading qualitative interviews with older people with complex living conditions.

BACKGROUND: By matching needs to resource services, case management could be a useful tool for improving the care of older people with complex living conditions. Collecting and analysing the users' experiences represents a good way to evaluate the effectiveness and efficiency of a case-management service. However, in the literature, fieldwork is very rarely considered and the users included in qualitative research seem to be the most accessible. AIM: This study was undertaken to describe the challenges of conducting qualitative research with older people with complex living conditions in order to understand their experiences with case-management services. METHODS: Reflective analysis was applied to describe the process of recruiting and interviewing older people with complex living conditions in private homes, describing the protocol with respect to fieldwork chronology. The practical difficulties inherent in this type of study are addressed, particularly in terms of defining a sample, the procedure for contacting the users and conducting the interview. The users are people who suffer from a loss of autonomy because of cognitive impairment, severe disease and/or psychiatric or social problems. Notably, most of them refuse care and assistance. RESULTS: Reflective analysis of our protocol showed that the methodology and difficulties encountered constituted the first phase of data analysis. CONCLUSION: Understanding the experience of users of case management to analyse the outcomes of case-management services requires a clear methodology for the fieldwork.

Analysis of case management programs for patients with dementia: a systematic review.

BACKGROUND: People suffering from dementia are particularly vulnerable to the gaps between the health and social service systems. Case management is a professional field that seeks to fill in these gaps and remedy this fragmentation. METHODS: We report the results of a systematic literature review of the impact of case management programs on clinical outcomes and the utilization of resources by persons with dementia. We focused on randomized controlled trials (RCTs) and attempted to identify the factors that might contribute to greater program efficacy. Because the evaluation methods in these studies varied, we used the effect size method to estimate the magnitude of the statistically significant effects reported. RESULTS: Our search strategy identified 17 references relating to six RCTs. Four of these six RCTs reported moderately statistically significant effects (effect size, 0.2-0.8) on their primary end point: the clinical outcome in three and resource utilization in one. Two of the RCTs reported weak or no effects (effect size, <0.2) on their primary end point. Because of the wide variety of the end points used, an overall effect size could not be calculated. Parameters that appear to be related to greater case management efficacy are the integration level between the health and social service organizations and the intensity of the case management. CONCLUSIONS: Integration and case management intensity seem to determine the magnitude of the clinical effects in this new professional field. Further studies are needed to clarify the economic impact.

The path dependency theory: analytical framework to study institutional integration. The case of France.

BACKGROUND: The literature on integration indicates the need for an enhanced theorization of institutional integration. This article proposes path dependence as an analytical framework to study the systems in which integration takes place. PURPOSE: PRISMA proposes a model for integrating health and social care services for older adults. This model was initially tested in Quebec. The PRISMA France study gave us an opportunity to analyze institutional integration in France. METHODS: A qualitative approach was used. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings, and administrative documents. RESULTS: Our analyses revealed the complexity and fragmentation of institutional integration. The path dependency theory, which analyzes the change capacity of institutions by taking into account their historic structures, allows analysis of this situation. The path dependency to the Bismarckian system and the incomplete reforms of gerontological policies generate the coexistence and juxtaposition of institutional systems. In such a context, no institution has sufficient ability to determine gerontology policy and build institutional integration by itself. CONCLUSION: Using path dependence as an analytical framework helps to understand the reasons why institutional integration is critical to organizational and clinical integration, and the complex construction of institutional integration in France.

Is the PRISMA-France glass half-full or half-empty? The emergence and management of polarized views regarding an integrative change process.

AIM: The PRISMA-France pilot project is aimed at implementing an innovative case management type integration model in the 20th district of Paris. This paper apprehends the emergence of two polarized views regarding the progression of the model's spread in order to analyze the change management enacted during the process and its effects. METHOD: A qualitative analysis was conducted based on an institutional change model. RESULTS: Our results suggest that, according to one view, the path followed to reach the study's current level of progress was efficient and necessary to lay the foundation of a new health and social services system while according to the other, change management shortcomings were responsible for the lack of progress. DISCUSSION: While neither of these two views appears entirely justified, analyzing the factors underlying their differences pinpoints some of the challenges involved in managing the spread of an integrated service delivery network. Meticulous preparation for the change management role and communication of the time and effort required for a wholesale institutional change process may be significant factors for a successful integrative endeavor.

[Level of evidence for case management in Alzheimer's disease: a literature review]. / Niveau de preuve de la gestion de cas dans la maladie d'Alzheimer : revue de littérature.

Alzheimer's disease or related diseases patients are particularly vulnerable to fragmentation of the French system of care and support. The government has decided to implement a national plan from which two key steps are the implementation of integration and case management. We report results of a review of the literature on both the definition of these concepts and their impacts as reported in randomized controlled studies. Important differences are noticeable between studies concerning the spectrum of integration (acute and long-term care, social and health sectors, institutional and liberal sectors and financing mode notably). Case-management has multiple sense, and it must be paid attention to intensity and context of the intervention. According to available evidence, case management is likely to improve, for the person with Alzheimer's, quality of care, quality of life and quality of life of caregivers at least. Conditions for a program to be successful are adequate targeting of the target population, sufficient level of integration and adequate intensity of case management. The programs most successful and most intensive relate an effect on prevention of loss of autonomy, even death, and no extra cost. The effects on hospitalization or entry into the institution are currently hypothetical and should be further studied.