CIHR Team in Frailty and Aging  

RP #5: Development, implementation and evaluation of a computerized care management system based on clinical care pathways for frail users of community-based integrated care.

PRINCIPAL INVESTIGATORS: N. Dubuc, M.Tousignant, L.Mathieu
Y. Couturier, D. Morin, A. Tourigny, L. Bonin.

OBJECTIVES: The main objective of this study is to develop, implement and assess computarized clinical care pathways (CCPs) for the disabled elderly (Iso-SMAF profiles) showing certain signs of frailty and monitored by interdisciplinary teams from the local services networks. The four specific objectives that will be achieved over a 5-year period are: 1) Creating (specifically for the elderly) appropriate CCPs for each autonomy profile including signs of frailty; 2) Taking part in the CCPs integration into the RSIPA software solution that is currently implemented in certain regions of Quebec; 3) Supporting the implementation of computarized CCPs in a CSSS (health and social services centre) and evaluating the implementation process of computarized CCPs; 4) Evaluating results with clinical professionals, managers and organizations regarding the use of computarized CCPs in this CSSS.

METHODS: The first objective consists of developing the CCPs content and will be based not only on evidence-based literature review but also on the expertise of clinicians, stakeholders and managers working in home care services (HCS) in Quebec . Several steps will be necessary to develop the CCPs:

1) Preparation of the required material to develop the CCPs will consist of six types of information :

A) CCPs’ expected attributes; B) Prevailing practices in regions: to this end, data will be collected from the Client Information System (CIS) database that relies on the CLSC’s normative framework and on previous file auditing. A total of 120 clinical records (30 per category of Iso-SMAF profile) of vulnerable elders who receive home support services from the Montérégie region will be reviewed. Review of clinical records will be performed with an assessment instrument that was created and validated during a previous study. Information gathered from this review will allow a better documentation of the prevailing practice and the creation of hypothetical clinical scenarios that will be illustrated by vignettes. Note that c linical information is available from the mandatory assessment form (OEMC) used in CSSSs. The OEMC includes information regarding health, lifestyle habits, the psychosocial situation, economic conditions and the physical environment, and assesses ADL, mobility, communications, mental functions and IADL using the SMAF. The SMAF served as a base for the development of the Iso-SMAF classification. The latter's 14 groups represent homogeneous groups of people characterized by different levels of cognitive decline and functional limitations. They can be grouped into four broad categories (Iso-4-SMAF): persons with disabilities in IADL; persons with disabilities in IADL and ADL and with major mobility problems; persons with disabilities in IADL and ADL with major cognitive problems; and persons with mixed problems (cognitive and mobility) and severe disabilities in IADL and ADL . C) The vignettes illustrate, in a standardized manner, different clinical conditions frequently experienced by the elderly using HCS (facing risks of frailty including Iso-SMAF autonomy profiles) as well as services provided by HCS. They will include data such as: descriptive specifications (age, gender, financial situation, health status, risk factors-depression, falls, malnutrition), the functional autonomy profile (cognitive or mobility impairments, heaviness), living habits, the psychosocial situation (isolation, social retrenchment) and the physical environment conditions; D) Best scientific evidence build on evidence-based practice: with literature review and documentation from professional associations and Quebec’s CSSS; E) Preferences in terms of care and services intended for the elderly and their informal caregivers: with qualitative interviews conducted with about 30 frail elders and members of their families. The Iso-SMAF profiles will be represented in this sample. The final number of interviews will depend on the degree of data saturation achieved. Participants will be selected among the 120 clinical records that were already reviewed. F) Examples of CCPs used for other situations: available in the literature review and others currently used in some regions of Quebec will be introduced.

2) Determining the best practices from a collective judgement of an interdisciplinary working group: a provincial interdisciplinary working group (PIWG) will have about 12 to 15 members. It will be mostly composed of clinicians, researchers, experts working in HCS services and specialized units such as the Functional Intensive Rehabilitation Units (FIRU) and the Short-Term Geriatric Care Units (STGCU) as well as short-term care emergency services from several regions of Quebec and representing rural, urban and metropolitan areas. Once they are selected, the experts will receive a folder that contains the information needed to create CCPs. Please note that a research assistant will attend the meetings in order to document the CCPs design process. This will be useful afterwards to create CCPs for other clienteles.

3) Validation with a group of experts (n=60) using the Delphi Method (according to the Rand/UCLA Technique): in order to ensure their acceptability, CCPs already developed will be submitted to approximately 60 experts from different locations in Quebec and representing rural, urban and metropolitan areas. The experts will be clinicians, managers, doctors, stakeholders (nurses, physiotherapists, occupational therapists, nutritionists, social workers, homemakers) who have an expertise or work with the frail elderly living in the community and show an interest in this study. A document (including information regarding project objectives, the task expected, the estimated length of work and the use of results of this consultation) will be sent by mail to experts who show an interest in participating in this validation process. Several steps of consultation will be necessary and a letter explaining the validation process will be included in the questionnaire for each step of the consultation. Experts will have three weeks to answer the questionnaire and to send it back. With this method, two or three rounds are generally enough. The second objective is aiming at the integration of the CCPs in the RSIPA Software Solution (project regarding the computarization of networks of integrated services for the elderly that is currently implemented in some Quebec regions) and includes the Soft System Methodology (SSM). Once completed, the validated CCPs will be computarized and integrated within the RSIPA software solution. Members of the research team will take part in meetings of the RSIPA computarization project with the Ministerial task force in order to ensure that the CCPs, once integrated in the RSIPA software solution, will be user-friendly for the local CSSS interdisciplinary teams, in their day-to-day practice, while making access easier for managers to useful data concerning decisions related to work organization, planning and continuing review of the quality of services. In order to know in which way the various steps of the Soft System Methodology (SSM) will be attained during the integration of computarized CCPs in the RSIPA solution, a follow-up will be performed by a research assistant. He/she will make observations and performed qualitative analyses of the committee meetings.

The third objective is taking an interest in the implementation of computarized CCPs and we will refer to the Swanson Model (1988) which includes nine key-factors to ensure the success of a system implementation. During the implementation process, a follow-up of activities will be established. It will include the analysis of the working group’s meeting summary report, some meetings between managers and other documents. Semi-structured individual interviews will be conducted with approximately 30 CCPs users (stakeholders from various professional fields, managers, partners). The recruitment process ends when data saturation is reached. From our previous experiences, we evaluate this number between 25 and 30 participants. During these 60-minute meetings, we will document favourable and restrictive factors in using CCPs. Participants will be selected according to the CCPs use in order to better recognize factors associated to low or high usage of CCPs. The content of these meetings will be recorded on audio cassettes. The transcript will be available for the analysis.

The forth objective is aiming at evaluating results related to the utilization of the system and using a successful model of an information system such as the DeLone and McLean (2003). To document the gap between what is prescribed by the CCPs and their use by different actors, data archives from the CIS-CLSC data bank and computarized CCPs integrated in the RSIPA solution will be extracted at two different times, at the beginning of the implementation process and a year after. The documented features will be: activities achieved, population contacted and people involved. In order to find out if relations between actors have been modified by the computarized CCPs implementation, two discussion groups of about 9 to 12 people will be set up and involve various computarized CCPs users. The 90-minute meetings will be recorded on audio cassettes. The transcript will be available for the analysis. In order to identify the perceived results of the computarized CCPs usage, data will be extracted from a self-administered questionnaire that will be sent to various CCPs users. It takes 20 minutes to fill out the questionnaire. In order to identify the adjustments to be made that will ensure a better congruence between the CCPs and the environment in which they are implemented, data collected during the implementation process will be submitted to the members of the provincial interdisciplinary task force. Adjustments could be related to the clientele, professional practices and the organization of network services. Potential solutions or recommendations could be formulated this way in order to refine and specify the CCPs.

TARGETED RESULTS: These new tools constituted of standardized information will allow a personalized approach and to have a better picture of each user. The coordination of services provided will be easier. This project will also allow the transfer of expertise, tools or clinical computarized modules that support an optimal use of CCPs for other vulnerable clienteles.

SCHEDULE: Oct. 2007-Sept. 2008: preparing and collecting information in medical records , CIS database query, Interviews with the frail elderly and their close relatives. Oct. 2008-Sept. 2009: verbatims and coding analyses, creation of Clinical Care Pathways (CCPs). Oct. 2009-Sept. 2010: performing the Delphi , collecting and analyzing Information System Data (IS), Developing the IS, beginning clinical implementation, individual interviews, group interviews, CCPs compliance data collection, meeting with the working committee. 2010-2011: adjustments and corrections of final CCPs, interviews with managers & stakeholders, gap study of implemented CCPs, gap analysis with experts. Oct. 2011-Sept. 2012: gap study of implemented CCPs, gap analysis with experts, end of data collecting, data final treatment, qualitative data analysis. Sept 2012- March 2012 : quantitative data analysis, final writing of the report.

INSTITUTIONAL SETTING : The project will take place in a CSSS (Jardins-Roussillon) of the Monteregie region.


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Updated February 11, 2013