PRISMA: a new model of integrated service delivery for the frail older people in Canada.

Purpose: PRISMA is an innovative co-ordination-type Integrated Service Delivery System developed to improve continuity and increase the efficacy and efficiency of services, especially for older and disabled populations.

Description: The mechanisms and tools developed and implemented by PRISMA include: (1) co-ordination between decision-makers and managers, (2) a single entry point, (3) a case management process, (4) individualised service plans, (5) a single assessment instrument based on the clients' functional autonomy, and (6) a computerised clinical chart for communicating between institutions for client monitoring purposes.

Preliminary Results: The efficacy of this model has been tested in a pilot project that showed a decreased incidence of functional decline, a decreased burden for caregivers and a smaller proportion of older people wishing to be institutionalised.

Conclusion: The on-going implementation and effectiveness study will show evidence of its real value and its impact on clienteles and cost.