This project evaluated a model of coordinated care for the frail elderly that was developed in 1997 in the Bois-Francs region of Quebec. Services to the elderly were coordinated by using one point of entry, case management, and personalized service plans ranging from health promotion to palliative care. A system of electronic clinical files was designed to facilitate interdisciplinary communication. The evaluation showed that the program succeeded in reaching the frail elderly, and that the intervenant-pivot (key practitioner) fulfilled the intended role of case manager. The computerized sharing of information was less successfully implemented because not everyone in the network was adequately equipped. The evaluation of patient outcomes showed a tendency for patients to stay longer in their homes in the Bois-Francs region than in the control region; family caregivers also reported a reduced burden for the first two years of the evaluation. No effect could be shown on the use of the emergency department, on hospitalization, or on medication usage. The companion project (QC-123) looks at the relative costs of the coordinated services and a control region; it concludes that costs were no higher for what appear to be generally improved outcomes for patients and their families.
This project was supported by the Health Transition Fund, which was created in 1997 to provide support for evidence-based decision-making in health care reform by supporting pilot and evaluation projects which test innovative approaches to health care delivery. The views expressed herein do no necessarily represent the official policy of federal, provincial, or territorial governments.