International Journal of Integrated Care, 29 April 2005 - ISSN 1568-4156
Book review
Integrated service delivery to ensure persons’ functional autonomy
Réjean Hébert, André Tourigny, Maxime Gagnon
2005, pp 323,
ISBN 2 89130 204 4
R.W. Haneveld, MD, PHS, MPH, ComplX Consultants b.v., The Hague, The Netherlands
Context and theme

Within consisting healthcare-systems innovations in service organizations are constantly being constructed due, for example, to new medical, governmental or managerial insights, political constrains and/or financial objectives. The socio-demographic changes in Canada, the increasing costs, shortage of personnel and dissatisfaction among elders with the traditional hospital-centred-model forced the Canadians towards innovation.

The book issue is relevant for all elders in the world: ‘How can one's functional autonomy at old age adequately be ensured?’


The book represents the struggle of researchers dealing with an innovation started in 1999 called Integrated Service Delivery (ISD) for the frail elders in three communities in Canada. Aspects of the Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) are highlighted in this 17-chapter book.

In Chapter 1 a description of the ISD model and the definition of integrated care are given. Chapter 2 deals with the necessary information and information-infrastructure (SIGG: Systeme d'information géronto-gériatrique; CCC: computerised clinical chart). In the Chapters 3 to 7 the authors discuss elements of successful implementation and evaluation. Chapter 8 deals with the validation of an abridged tool, the so-called PRISMA-7 Questionnaire. This tool can be used as a replacement for the SMAF-score (Systeme de mesure de l'autonomie fonctionelle) for the loss of autonomy. In Chapters 9 and 10 ISO-SMAF profiles are discussed. These profiles respond to the needs and demands of the elderly and can automatic monitor changes in status. In Chapter 11 the ISO-SMAF profiles are used to calculate medication costs. The calculation method is new and could prove useful in future research. In Chapter 12 the issue of public funding of home care services for frail elders is addressed. ISO-SMAF can help determine financial compensation. Chapter 13: the use of ISO-SMAF profiles in financial research is an innovation in itself, and is proven useful for decision-makers. The Chapters 14 to 16 deal with several outcome parameters like satisfaction (Chapter 14), the use of individual service plans (Chapter 15), the quality of care and services (Chapter 16). On satisfaction contradictory results are found. The individual service plans seem to be highly variable on outcome. This is due to variation in content, form, concept convenience and/or utilization. The quality and continuity of care in the Canadian context was proven valid, but has to be proven valid in other contexts. In the final Chapter 17, the overall complexity of system change is mentioned and warning is given to researchers to be cautious in generalizing their findings. Throughout the book explicit attention is paid to the chosen research methodology in public health research.

What is good?

This book illustrates the importance of integration of multidisciplinary care, public/private funding, governmental support and support of all relevant actor-groups in achieving an integrated care system for elders.

What can be better?

The book gives no exact answer to the question; ‘Can ISD ensure persons’ functional autonomy?’ The authors make statements on elements and show preliminary strengths and weaknesses overseeing a period of 5 years. The overall impression is, that in the situational context, the first results are promising. Definite proof lies in the results on the long-term.

In order to answer the question whether or not this Canadian Model can be copied into other healthcare-systems dealing with frail elders, additional research has to be done, for instance system analysis, longitudinal follow-up, political stability in policy strategies and funding innovations in public health and healthcare systems.

The involvement of doctors / Public Health Specialists in changes in healthcare-systems is essential to success.


This book is wonderful for researchers and medical doctors in the field of Public Health. The authors are capable of sharing doubts and decisions in applied scientific research involving healthcare-systems change. For people involved with Integrated Care projects this book is useful for background information.

A very smart and easy to implement tool is the valid proven PRISMA-7 Questionnaire.

Representative policy makers in ‘care for the elderly’ have to wait for the long-term results and the research project evaluations.


This book is best seen as an interim evaluation of ongoing research. It is too early for full implementation in other countries. Pilots elsewhere based on this work are a good alternative.


Special about this book is the combination of both innovation in healthcare and research. The challenge for researchers is to implement this concept in a pilot in other countries and settings, and to improve this concept.

The techniques of statistical analysis are understandable and logic within the re-search framework. Scientific debate on the adequacy of these techniques is required.