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Research & theory

Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people

Authors:

Nicole Dubuc ,

CA
About Nicole

PhD, Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, and Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada

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Lucie Bonin,

CA
About Lucie

MD, Agence de la santé et des services sociaux de la Mauricie-Centre-du-Québec, Trois-Rivières, Québec, Canada

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André Tourigny,

CA
About André

MD, Institut national de santé publique du Québec, Centre de recherche du Centre hospitalier affilié, Québec, Canada

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Luc Mathieu,

CA
About Luc

PhD, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada

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Yves Couturier,

CA
About Yves

PhD, Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, and Faculty of Arts, Humanities and Social Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada

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Michel Tousignant,

CA
About Michel

PhD, Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, and Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada

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Cinthia Corbin,

CA
About Cinthia

MA, Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Québec, Canada

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Nathalie Delli-Colli,

CA
About Nathalie

PhD(c), Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, and Faculty of Arts, Humanities and Social Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada

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Michel Raîche

CA
About Michel

PhD, Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, Québec, Canada

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Abstract

Introduction: The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow up frail and disabled community-dwelling older people.

Theory and method: A rigorous process was applied according to a series of steps: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team.

Results: ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans.

Conclusion: Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

How to Cite: Dubuc N, Bonin L, Tourigny A, Mathieu L, Couturier Y, Tousignant M, et al.. Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people. International Journal of Integrated Care. 2013;13(2):None. DOI: http://doi.org/10.5334/ijic.976
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Published on 21 May 2013.
Peer Reviewed

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