Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. Prospero registration number: 42016037725
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The effects of integrated care: a systematic review of UK and international evidence

Background: frailty is a state of vulnerability to adverse outcomes. Routine identification of frailty is recommended in international guidance. This systematic review investigates the diagnostic test accuracy (DTA) of simple instruments for identifying frailty in community-dwelling older people. Methods: the review methodology followed Cochrane procedures. Databases were searched from January 1990 to October 2013. Prospective studies assessing the DTA of simple instruments for identifying frailty in community-dwelling older people (aged ≥65 years) as index tests against a reference standard phenotype model, cumulative deficit frailty index or comprehensive geriatric assessment were eligible for inclusion. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated for index tests. Risk of bias was assessed using the QUADAS-2 checklist. Results: three studies involving 3,261 participants were included. Median frailty prevalence was 10.5%. Seven index tests were assessed: gait speed, timed-up-and-go test, PRISMA 7 questionnaire, self-reported health, general practitioner clinical assessment, polypharmacy and Groningen Frailty Index. For a gait speed of <0.8 m/s, the sensitivity = 0.99 and specificity = 0.64. For the PRISMA 7, the sensitivity = 0.83 and specificity = 0.83. For the timed get-up-and-go test of 10 s, the sensitivity = 0.93 and specificity = 0.62. DTAwas notably lower for all other index tests. All three studies were judged at unclear risk of bias. Discussion: slow gait speed, PRISMA 7 and the timed get-up-and-go test have high sensitivity for identifying frailty. However, limited specificity implies many false-positive results which means that these instruments cannot be used as accurate single tests to identify frailty.

Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review

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Journey of Caring: an analysis of long-term care for Dementia.

Frailty is the loss of resources in several domains leading to the inability to respond to physical or psychological stress. The evaluation of frailty is generally carried out using the Comprehensive Geriatric Assessment. For this evolving and potentially reversible syndrome, screening and early intervention are a priority in primary health care, and general practitioners require a simple screening tool. The aim of the present work was to review the literature for validated screening instruments for frailty in primary health care setting. A search was carried out on PubMed and Cochrane Central in June 2011. A total of 10 instruments screening for frailty in primary health care were listed, analysed and compared. It is difficult to show which tool today is the best for screening for frailty in the elderly in primary care settings. Two instruments are potentially suitable – the Tilburg Frailty Indicator and the SHARE Frailty Index. In addition, these instruments require validation in larger studies in primary health care settings and with more quality criteria. Geriatr Gerontol Int 2012; 12: 189–197.

http://gero.usc.edu/AgeWorks/spring_session2015/tdl/gero510/gero510-2013pdfs/wk1-Geriatric-Assessment/FrailtyScreeningTools.pdf

Screening tools for frailty in primary health care: A systematic review

Objectives . To evaluate the impact of a coordination-type integrated service delivery (ISD) model on health, satisfaction, empowerment, and services utilization of frail older people. Methods . Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is a populationbased, quasi-experimental study with three experimental and three comparison areas. From a random selection of people 75 years or older, 1,501 persons identifi ed at risk of functional decline were recruited (728 experimental and 773 comparison). Participants were measured over 4 years for disabilities (Functional Autonomy Measurement System), unmet needs, satisfaction with services, and empowerment. Information on utilization of health and social services was collected by bimonthly telephone questionnaires. Results . Over the last 2 years (when the implementation rate was over 70%), there were 62 fewer cases of functional decline per 1,000 individuals in the experimental group. In the fourth year of the study, the annual incidence of functional decline was lower by 137 cases per 1,000 in the experimental group, whereas the prevalence of unmet needs in the comparison region was nearly double the prevalence observed in the experimental region. Satisfaction and empowerment were signifi cantly higher in the experimental group. For health services utilization, a lower number of visits to emergency rooms and hospitalizations than expected was observed in the experimental cohort. Conclusion . The PRISMA model improves the effi cacy of the health care system for frail older people.

Impact of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-experimental Study

Purpose: The PRISMA study analyzes an innovative coordination-type integrated service delivery (ISD) system developed to improve continuity and increase the effectiveness and efficiency of services, especially for older and disabled populations. The objective of the PRISMA study is to evaluate the effectiveness of this system to improve health, empowerment and satisfaction of frail older people, modify their health and social services utilization, without increasing the burden of informal caregivers. The objective of this paper is to present the methodology and give baseline data on the study participants. Methods: A quasi-experimental study with pre-test, multiple post-tests, and a comparison group was used to evaluate the impact of PRISMA ISD. Elders at risk of functional decline (501 experimental, 419 control) participated in the study. Results: At entry, the two groups were comparable for most variables. Over the first year, when the implementation rate was low (32%), participants from the control group used fewer services than those from the experimental group. After the first year, no significant statistical difference was observed for functional decline and changes in the other outcome variables. Conclusion: This first year must be considered a baseline year, showing the situation without significant implementation of PRISMA ISD systems. Results for the following years will have to be examined with consideration of these baseline results.

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The effectiveness of the PRISMA integrated service delivery network: preliminary report on methods and baseline data

PRISMA is the only example of a co-ordinatedtype model to be developed and fully implemented with a process and outcome evaluation. The PRISMA model was implemented in three areas (urban, rural with or without a local hospital) in Quebec, Canada and an implementation evaluation was carried out using mixed (qualitative and quantitative) methods. Over four years, the implementation rates went from 22% to 79%. The perception of integration by managers and clinicians working in the various organisations of the network shows that most

Evaluation of the Implementation of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older

PRISMA is the only example of a co‐ordinated‐type model to be developed and fully implemented with a process and outcome evaluation. The PRISMA model was implemented in three areas (urban, rural with or without a local hospital) in Quebec, Canada and an implementation evaluation was carried out using mixed (qualitative and quantitative) methods. Over four years, the implementation rates went from 22% to 79%. The perception of integration by managers and clinicians working in the various organisations of the network shows that most interactions are perceived as at the co‐operation level, some getting the highest collaboration level. The perception of the efficacy of case managers was very high. Implementing such a model is feasible, and the decision to generalise it was made in Quebec. This model might be more appropriate for a universal publicly funded health care system like those in Canada, the UK and the Scandinavian countries.

Evaluation of the Implementation of PRISMA, a Coordination‐Type Integrated Service Delivery System for Frail Older People in Québec

OBJET: Le projet PRISMA (Programme de recherche sur l’integration des services de maintien de l’autonomie) etudie un reseau integre de services pour personne âgees (RISPA) de type coordination developpe pour ameliorer la continuite et accroitre l’efficacite et l’efficience des services. L’objectif de l’etude PRISMA est d’evaluer l’efficacite populationnelle de ce reseau a ameliorer l’autonomie, l’autonomisation et la satisfaction des personnes âgees fragiles, modifier leur utilisation des services de sante et services sociaux, et reduire le fardeau de leurs aidants. METHODOLOGIE: Une etude quasi-experimentale avec pre-test, post-tests multiples et groupe de comparaison a ete utilisee pour evaluer les impacts du RISPA. 1501 sujets âges a risque de perte d’autonomie (728 experimentaux, 773 temoins) ont participe a l’etude. RESULTATS: Les sujets du groupe experimental ont montre une reduction significative de la prevalence (6,2%) et de l’incidence (13,7%) de la perte d’autonomie avec une reduction des besoins non combles de 31%. La satisfaction et l’autonomisation se sont ameliorees. Une reduction des visites a l’urgence et des hospitalisations a aussi ete observee sans augmentation des couts des services. CONCLUSION: Le modele de coordination PRISMA est praticable et efficient dans le contexte sociosanitaire quebecois et merite d’etre adapte a d’autres contextes.

Marie-France Dubois

Papers

Impact of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-experimental Study

The effectiveness of the PRISMA integrated service delivery network: preliminary report on methods and baseline data

Evaluation of the Implementation of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older

Evaluation of the Implementation of PRISMA, a Coordination‐Type Integrated Service Delivery System for Frail Older People in Québec

Les impacts du réseau intégré de services PRISMA