SIPA Demonstration Project
SIPA Demonstration Project: implementation and assessment
The SIPA demonstration project, based on the previously described model, was a community program that assumed clinical and administrative responsibility for all services required by frail elderly participants. The clinical aspect of this demonstration project was organized around a multidisciplinary team and case manager. The service plan, as well as its execution and follow-up, were the responsibility of this team and the individuals associated with it. Lastly, the demonstration project operated within the context of Canadian and Quebec health-related legislation. Through the addition of a significant number of community resources, case management, a team structure for care delivery, clinical responsibility for all care, and cooperation between institutions, this project represented a major operational change within the Quebec health and social service system. However, its orientations and operational methods were consistent with the orientations of this system’s current efforts at reform.
The demonstration project took place at two CLSC sites located in Montreal, i.e., the CLSC Côte-des-Neiges and the CLSC Bordeaux-Cartierville. The project differed from the model in that it did not assume financial responsibility for the short- and long-term care and services utilized by the elderly persons admitted to it.
The demonstration project was evaluated by the RRSSSM-C at the SOLIDAGE Université de Montréal—McGill University Research Group on Integrated Services for Older Persons.
The assessment was intended to allow researchers to examine the ability of the demonstration project to apply the SIPA clinical and organizational models, alter the configuration of care and services, monitor costs, and guarantee quality of care. In other words, the purpose of the demonstration project and assessment was to examine whether or not SIPA, in comparison to the current system, was able to meet the needs of vulnerable older persons through appropriate, high-quality care and services, as a cost equal to the services currently available to this population.
The objectives of the SIPA demonstration project assessment were:
- to examine the ability to establish and organize services according to the SIPA model;
- to evaluate the quality of care and services provided;
- to examine the ability of the SIPA project to meet the needs of frail elderly persons and verify its impact on their state of health;
- to make sure that patterns of service utilization were consistent with the SIPA model; and
- to obtain a cost estimate and compare the costs of services provided to those in the SIPA group to those associated with services provided to a comparable group of older persons.
The examination of various aspects of this assessment was subject to a multifaceted methodological process, in which various study designs, and several observational and data analysis procedures were used. Several types of data were required, including data on the establishment and organization of SIPA, quality of care, the health of the older persons and caregivers participating, their patterns of health and social service use, and the costs of services.
The older persons recruited for the demonstration project were selected from among the patients, aged 65 or over, registered for home support services with the CLSC Côte-des-Neiges and the CLSC Bordeaux-Cartierville. The older persons were recruited by the clinical personnel working for the CLSC home support services department, for an evaluation of their functional ability according to the SMAF instrument (Hébert et al., 1988). This instrument is part of the multi-clientele form used by CLSCs in the Montreal area to determine the overall needs of patients admitted to the home support services program. Those with a SMAF score of 10 or higher were asked to participate in the study. Those who did not meet this criterion were excluded.
Case study: The case study method was the research strategy chosen to analyse the influence of the organizational and interorganizational context on the degree of implementation of SIPA (Yin, 1989). Each experimental site constituted one analytical unit that was followed longitudinally in order to understand the dynamics of implementation (Patton, 1990).
Experimental design: An experimental protocol (randomized clinical trial) was used to evaluate service utilization and costs, as well as the state of health of the older persons and caregivers participating in the study. A total of 1230 frail older persons were recruited. These individuals were randomly assigned to either the experimental group (to receive care according to the SIPA model) or the control group (to receive the usual care offered by the CLSC).
Consent to participate in the study included an agreement regarding random assignment to either the experimental or control group; participation in interviews with open- or closed-ended questions; and agreement to allow examination of their social service, medical and hospital records and MED-ECHO administrative files kept by the Quebec Ministry of Health and Social Services and the Régie de l’assurance maladie du Québec (RAMQ). Participant’s RAMQ identification numbers were requested.
The recruitment process was carried out from January to August 1999. Participants were randomly assigned either to the experimental or control group. Individuals were excluded from the demonstration project if they were planning to move out of the CLSC territories within the following six months; waiting to be placed in a chronic care institution; researchers were unable to obtain consent from a caregiver on behalf of a person unable to provide enlightened consent; or the principal caregiver refused to participate. One individual in the eligible subject’s home had to understand either French or English.
Various collection procedures were utilized: direct observation, case study, semi-structured interviews, regular interviews, closed-ended questionnaires, and examination of social service, medical or hospital records and administrative files. The establishment and organization of SIPA was examined via observation and open-ended interviews. Quality of care was analysed via qualitative and quantitative observation. Data on state of health, socio-economic status, assistance received, some of the care and services received, private costs for home support services, and caregiver burden were collected via closed-end questionnaires. Data on patterns of use and costs of services were obtained via examination of institutional social service, medical and hospital records, and computer files kept by institutions, the Regional Health Board and the Ministry of Health and Social Services.