Frail elderly patients. New model for integrated service delivery.

Problem Being Addressed: Given the complex needs of frail older people and the multiplicity of care providers and services, care for this clientele lacks continuity.

Objective Of Program: Integrated service delivery (ISD) systems have been developed to improve continuity and increase the efficacy and efficiency of services.

Program Description: 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.

Conclusion: 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.