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1.  Multidisciplinary teams of case managers in the implementation of an innovative integrated services delivery for the elderly in France 
Background
The case management process is now well defined, and teams of case managers have been implemented in integrated services delivery. However, little is known about the role played by the team of case managers and the value in having multidisciplinary case management teams. The objectives were to develop a fuller understanding of the role played by the case manager team and identify the value of inter-professional collaboration in multidisciplinary teams during the implementation of an innovative integrated service in France.
Methods
We conducted a qualitative study with focus groups comprising 14 multidisciplinary teams for a total of 59 case managers, six months after their recruitment to the MAIA program (Maison Autonomie Integration Alzheimer).
Results
Most of the case managers saw themselves as being part of a team of case managers (91.5%). Case management teams help case managers develop a comprehensive understanding of the integration concept, meet the complex needs of elderly people and change their professional practices. Multidisciplinary case management teams add value by helping case managers move from theory to practice, by encouraging them develop a comprehensive clinical vision, and by initiating the interdisciplinary approach.
Conclusions
The multidisciplinary team of case managers is central to the implementation of case management and helps case managers develop their new role and a core inter-professional competency.
doi:10.1186/1472-6963-14-159
PMCID: PMC4021253  PMID: 24708721
Case management team; Multidisciplinary; Case managers; Integration
2.  Adapting the Quebecois method for assessing implementation to the French National Alzheimer Plan 2008–2012: lessons for gerontological services integration 
Introduction
Many countries face ageing-related demographic and epidemiological challenges, notably neurodegenerative disorders, due to the multiple care services they require, thereby pleading for a more integrated system of care. The integrated Quebecois method issued from the Programme of Research to Integrate Services for the Maintenance of Autonomy inspired a French pilot experiment and the National Alzheimer Plan 2008–2012. Programme of Research to Integrate Services for the Maintenance of Autonomy method implementation was rated with an evaluation grid adapted to assess its successive degrees of completion.
Discussion
The approaching end of the president's term led to the method's institutionalization (2011–2012), before the implementation study ended. When the government changed, the study was interrupted. The results extracted from that ‘lost’ study (presented herein) have, nonetheless, ‘found’ some key lessons.
Key lessons/conclusion
It was possible to implement a Quebecois integrated-care method in France. We describe the lessons and pitfalls encountered in adapting this evaluation tool. This process is necessarily multidisciplinary and requires a test phase. A simple tool for quantitative assessment of integration was obtained. The first assessment of the tool was unsatisfactory but requires further studies. In the meantime, we recommend using mixed methodologies to assess the services integration level.
PMCID: PMC4063544  PMID: 24959112
method of integrated care; assessment of implementation; geriatric services integration
4.  The French Society of Geriatrics and Gerontology position paper on the concept of integration 
Introduction
The concept of integration, although dating from the 1990s, has only recently appeared in French public health policy. It must be linked with ‘coordination’, which is the base of most French public policies applied to geriatrics since the 1960s. Herein, we report the French Society of Geriatrics and Gerontology working group's findings according to three axes: definition of integration, objectives of this organisational approach and the means needed to achieve them.
Discussion
Integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, financing, interventions and action-reports on the latter. Integration must be accompanied by a local dedicated professional (the ‘pilot’). Results of recent experiments showed that it is possible to implement integrative dynamics in France.
PMCID: PMC4027931  PMID: 24868197
position paper; definition; integration; geriatrics
5.  General practitioner’s clinical practices, difficulties and educational needs to manage Alzheimer’s disease in France: analysis of national telephone-inquiry data 
BMC Family Practice  2013;14:81.
Background
The literature has emphasized the role of general practitioners (GPs) in caring for Alzheimer’s disease (AD) patients. Within the framework of the French national AD plan, an inquiry was undertaken to identify the clinical practices, difficulties and training needs of GPs managing this pathology.
Methods
A random sample from a representative national listing of continental French GPs following ≥1 AD patients comprised the study population. Participants completed a standard questionnaire on their clinical practices, difficulties and educational needs for AD management. Feeling insufficiently trained was subjected to univariate and multivariate analyses.
Results
A minority of the 974 respondents declared using questionnaires in their diagnostic evaluation (15.2%), told the patient the diagnosis (8.2%) and was aware of the national recommendations for AD (41.9%). Behavioral disorders represented the most common (73.5%) problem encountered, while half of the GPs considered management of comorbidities easy roles to fulfill. In comparison, coordination of care and assistance did not seem to be a primary problem. A score was calculated, attributing 1 point to each of the following items: need for further education in terms of communications with the family, with patients, disclosing the diagnosis, and non-drug treatments. The factors linked to feeling insufficiently trained for 3 or 4 of the 4 items were: female sex; not involved in educational programs (for parents/family and patients) and no activity related to training medical students.
Conclusions
Our study identified gaps in French GP training concerning AD diagnosis practices and diagnosis announcement. GPs seemed aware of their educational needs and described difficulties in managing behavioral disorders. Our findings enabled the definition of policy priorities to provide training and disseminate information.
doi:10.1186/1471-2296-14-81
PMCID: PMC3682915  PMID: 23763854
Alzheimer’s disease; Opinion inquiry; Educational needs
6.  Institutional change and Institutional Integration in France: Health Regional Agencies what consequences for the development of integrated services delivery? 
Purpose
In France, the development of integrated services delivery for elderly (ISDE) has been hindered by the fragmentation of the decision-making institutions. By merging the healthcare and medicosocial institutions, the Health Regional Agencies (HRA), responsible for developing ISDE, theoretically constitutes a solution. The study examines how the HRA received and implemented the legislative mandate of the development of the ISDE.
Theory
We used the model of “receptivity to change strategic” developed by A.M. Pettigrew in the context of reforms of the National Health Service (NHS).
Method
An empirical study was conducted in 2011 in two phases: 1) 10 case studies of HRA, 2) questionnaire sent to all 26 HRAs.
Results and conclusion
The concentration of the decision powers in HRAs favors the deployment of ISDE. Three considerations limit this consideration: 1) lack of legislative instruments allows the HRA to reproduce a fragmented internal organization; 2) lack of prerogative on the social institutions; these institutions can develop contradictory policies; 3) new definition of norms and governance may slow down the deployment of ISDE.
Discussion
The deployment of ISDE relies on regional institutions that are subjected to changes. The on-going analysis will determine whether the new frames of reference and governance comply with the principles of services integration.
PMCID: PMC3617741
integrated networks; institutional integration; institutional change; Social healthcare system
7.  Moving toward integrating care in France: factors related to local managers 
Purpose
The 2008–2012 French Alzheimer plan aims to implement an integrated services delivery (ISD) called “Homes for Integration and Autonomy for Alzheimer patients”. Alzheimer disease is taken as a model to implement ISD in the whole system. All pilot projects were driven by a ‘local pilot’ fully dedicated to the ISD implementation.
Methods
We aimed to analyze factors related to the ‘local pilot’ in regard of the implementation of the national public health policy. We conducted interviews of all ‘local pilots’ (n=19) in 2010, their project’s structure managers (n=19) and case managers (17 focus groups). We crossed our results with the external follow-up by the national project team.
Results
Main influencing factors of the ISD implementation were: 1) professional autonomy of the pilot; 2) good positioning of the project’s structure manager; 3) project’s management competency of the pilot; 4) support query by the pilot from the national project team; 5) links between case managers and pilot; and 6) the articulation modality of eventual multiple pilots or managers.
Discussion and conclusions
It was previously shown that it is crucial for ISD implementation to have a dedicated professional for this task. The French national Alzheimer plan gave us an opportunity to analyze factors related to the modality of doing this task.
PMCID: PMC3617772
local management; integrated services delivery; qualitative analysis
8.  Institutional change and Institutional Integration in France: Health Regional Agencies. What consequences for the development integrated services delivery? 
Purpose
In France, the development of integrated services delivery for elderly (ISDE) has been hindered by the fragmentation of the decision-making institutions. By merging the healthcare and medicosocial institutions, the Health Regional Agencies (HRA), responsible for developing ISDE, theoretically constitutes a solution. The study examines how the HRA received and implemented the legislative mandate of the development of the ISDE.
Theory
We used the model of “receptivity to change strategic” developed by A.M Pettigrew in the context of reforms of the National Health Service (NHS).
Method
An empirical study was conducted in 2011 in two phases: 1) 10 case studies of HRA, 2) questionnaire sent to all 26 HRAs.
Results and conclusion
The concentration of the decision powers in HRAs favors the deployment of ISDE. Three considerations limit this consideration: 1) lack of legislative instruments allows the HRA to reproduce a fragmented internal organization; 2) lack of prerogative on the social institutions; these institutions can develop contradictory policies; 3) new definition of norms and governance may slow down the deployment of ISDE.
Discussion
The deployment of ISDE relies on regional institutions that are subjected to changes. The on-going analysis will determine whether the new frames of reference and governance comply with the principles of services integration.
PMCID: PMC3617774
integrated networks; institutional integration; institutional change; social healthcare system
9.  Implementation of the case management and interdisciplinary approach in an innovative integrated services delivery in France 
Purpose
The 2008–2012 French Alzheimer plan is marked by the experimental implementation of “Homes for Integration and Autonomy for Alzheimer patients” with implementation of intensive case management process for people in complex situation. In 17 experimental sites, teams of case managers (CMs) have been implemented with a total of 67 case managers for performing an intensive case management.
Methods
We conducted a qualitative study to develop a full understanding concerning the implementation of the case management process and the links with the interdisciplinary approach. Focus groups were conducted in 2010 to explore the perceptions of case managers six months after their recruitment.
Results
Interdisciplinary approach inside the case managers’ team has been rapidly constructed to resolve the complex situations, homogenize practices and help to create the new competency. Multidisciplinary and proximity team, common training and difficulties to get the good fit with professionals increased the interdisciplinary approach inside the case managers’ team. Interdisciplinary approach between case managers and clinical professionals was few implemented because of the high level of fragmentation and lack of case managers legitimacy.
Discussion
Implementation of intensive case management in an innovative integrated services delivery showed a stronger interdisciplinary approach between case managers compared to with clinical professionals.
PMCID: PMC3617782
case management; interdisciplinary practices; integrated services delivery
10.  The case manager through the eyes of the users: benefits and failures of a French case management experimentation 
Purpose
The PRISMA France project consists in the implementation of a global services integration in which a case management services is dedicated to old people with complex needs. One of the purposes of the research team was to analyze the representations of the users, i.e., the old people and their proxies, of the case management service through their own experience of profane expert.
Theory
According to the literature that deals with qualitative interviewing, we consider that the users of case management are able to express themselves on the benefit and the failures of the case management services even if some of them suffer from cognitive impairments.
Methods
In this view, 30 comprehensive and semi-structured talks were done, 19 old people and 11 proxies. All the interviews were face to face interview and were done by an anthropologist. The interviews were transcribed verbatim and analyzed by focusing on the node of sense in the user’s words.
Results and conclusions
On one side, the proxies describe the case manager as the one who give answers face to the complexity of the system. On the other side, the old people insisted on the relationship established with their case manager. She/he is the one who listens and asks questions in order to help them.
Discussion
The analysis of the user’s representations raises three main points:
Is the main role of the case manager is to bring an answer to the failures of the system?
By basing their representation of the case management on relational continuity, the old people reduce the work of the case manager of the work he/she done at home. So, when the presence of the case manager diminished, old people think that his/her work in not efficient.
How the policy makers could include the user’s points of view in the implementation of such kind of service?
PMCID: PMC3617784
case management; user’s representations; qualitative analysis
11.  Variability of Intensive Care Admission Decisions for the Very Elderly 
PLoS ONE  2012;7(4):e34387.
Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83–91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear.
Trial Registration
ClinicalTrials.gov NCT00912600
doi:10.1371/journal.pone.0034387
PMCID: PMC3324496  PMID: 22509296
12.  Ten years of integrated care for the older in France 
International Journal of Integrated Care  2011;11(Special 10th Anniversary Edition):e141.
Background
This paper analyzes progress made toward the integration of the French health care system for the older and chronically ill population.
Policies
Over the last 10 years, the French health care system has been principally influenced by two competing linkage models that failed to integrate social and health care services: local information and coordination centers, governed by the social field, and the gerontological health networks governed by the health field. In response to this fragmentation, Homes for the Integration and Autonomy for Alzheimer patients (MAIAs) is currently being implemented at experimental sites in the French national Alzheimer plan, using an evidence-based model of integrated care. In addition, the state’s reforms recently created regional health agencies (ARSs) by merging seven strategic institutions to manage the overall delivery of care.
Conclusion
The French health care system is moving from a linkage-based model to a more integrated care system. We draw some early lessons from these changes, including the importance of national leadership and governance and a change management strategy that uses both top-down and bottom-up approaches to implement these reforms.
PMCID: PMC3284287  PMID: 22375101
France; health and social integration; gerontology
13.  Institutional integration in France: Health Regional Agencies and integrated services delivery 
Introduction
The PRISMA France pilot project is ongoing since 2006. This project aims to implement an integrated services delivery (ISD) for elderly people, based on the PRISMA methodology. The experimentation is coupled with an implementation study to identify factors that facilitate and hinder the implementation. The fragmentation of public authorities represents one of the first barriers identified.
In 2009, a large-scale institutional reform has been initiated. It consists of merging various structures having strategic authorities on medical and social care within a single entity: the Health Regional Agencies (HRA). One could anticipate that this reform should facilitate the implementation of ISD.
Aims
To analyze the influence of institutional reforms on a pilot program aiming to implement an ISD. In the framework of our qualitative study we analyze the way the actors conceive the HRA.
Conclusions
The potential to facilitate ISD of the HRA has been identified. It is hope that they should reduce the institutional fragmentation. Nonetheless, the link between these agencies and the implementation of ISD in the pilot project was rarely made.
The extent of institutional change is bought into question by the past of the French system of social welfare.
PMCID: PMC3031844
integrated networks; PRISMA; implementation study; institutional fragmentation; Regional Agencies of Health
15.  The path dependency theory: analytical framework to study institutional integration. The case of France 
Background
The literature on integration indicates the need for an enhanced theorization of institutional integration. This article proposes path dependence as an analytical framework to study the systems in which integration takes place.
Purpose
PRISMA proposes a model for integrating health and social care services for older adults. This model was initially tested in Quebec. The PRISMA France study gave us an opportunity to analyze institutional integration in France.
Methods
A qualitative approach was used. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings, and administrative documents.
Results
Our analyses revealed the complexity and fragmentation of institutional integration. The path dependency theory, which analyzes the change capacity of institutions by taking into account their historic structures, allows analysis of this situation. The path dependency to the Bismarckian system and the incomplete reforms of gerontological policies generate the coexistence and juxtaposition of institutional systems. In such a context, no institution has sufficient ability to determine gerontology policy and build institutional integration by itself.
Conclusion
Using path dependence as an analytical framework helps to understand the reasons why institutional integration is critical to organizational and clinical integration, and the complex construction of institutional integration in France.
PMCID: PMC2916113  PMID: 20689740
integrated care; institutional integration; path dependence; gerontology
16.  Is the PRISMA-France glass half-full or half-empty? The emergence and management of polarized views regarding an integrative change process 
Aim
The PRISMA-France pilot project is aimed at implementing an innovative case management type integration model in the 20th district of Paris. This paper apprehends the emergence of two polarized views regarding the progression of the model's spread in order to analyze the change management enacted during the process and its effects.
Method
A qualitative analysis was conducted based on an institutional change model.
Results
Our results suggest that, according to one view, the path followed to reach the study's current level of progress was efficient and necessary to lay the foundation of a new health and social services system while according to the other, change management shortcomings were responsible for the lack of progress.
Discussion
While neither of these two views appears entirely justified, analyzing the factors underlying their differences pinpoints some of the challenges involved in managing the spread of an integrated service delivery network. Meticulous preparation for the change management role and communication of the time and effort required for a wholesale institutional change process may be significant factors for a successful integrative endeavor.
PMCID: PMC2807121  PMID: 20087426
change management; institutional change; integrated care; networks
17.  Analysis of the French system for persons in complex situation in regard of the implementation of a public policy aiming to integrate health and social services 
Introduction
The French Alzheimer plan, states that one of its principle orientations is the implementation of ‘Homes for Integration and Autonomy for Alzheimer patients’. Alzheimer disease is taken as a model to implement integration for all persons in complex situation (handicap…).
Method
Seventeen experimental sites were selected in January 2009 for the first two years. They were selected by policy-makers taking into account the readiness of the local policy-makers to implement the program, the diversity of sizes of sites, the diversity of the experimentation leaders' organizational link (public administrations, not for profit organizations, private organizations) and the diversity of societal structure (rural, urban and mega-urban). The experimental sites were analyzed considering six components of integration: coordination boards, unique point of access, case-management, standardized assessment tool, individualized services plan and information system. A complete and computerized tool was specifically developed for the organizational diagnosis.
Results
During the session, results will be exposed. These results will give a contrasted image of the French system for persons in complex situation. The tool will be also exposed and the receptivity will be discussed.
Conclusion
The French Alzheimer plan gives a unique opportunity to have a portrait of the French system in regard of integration challenges.
PMCID: PMC2807107
national public policy; Alzheimer disease; organizational tools; integrated health care networks; France
18.  PRISMA in Québec and France: implementation and impact of a coordination-type integrated service delivery (ISD) system for frail older people 
Introduction
Several models of integrated service delivery (ISD) networks are presently experimented in Canada and elsewhere, but most of them are designed according to a full integration model (PACE, S-HMO, SIPA). PRISMA is the only example of a coordinated-type model to be developed and fully implemented with a process and outcome evaluation.
The PRISMA model includes the following components to enhance the integration: 1) co-operation between decision-makers and managers of all services and institutions, 2) the use of a single entry point, 3) case management process, 4) individualized service plans, 5) a unique disability-based assessment tool (SMAF) with a case-mix system (Iso-SMAF profiles) and case-finding tool (PRISMA-7), and 6) a computerized system for communicating between institutions and professionals.
The PRISMA model
The PRISMA model was implemented in three areas (urban, rural with or without a local hospital) in Québec, Canada and research was carried out using both qualitative and quantitative data to evaluate its process and impact. An efficiency study was carried out, considering societal costs and all population impacts.
Based on the population impact demonstration, the PRISMA model has also been adapted and implemented in France. This symposium will present the implementation, impact and efficiency of the Québec experimentation, and the implementation transfer in France.
The 4 abstracts related to this project presentation:
1. Description and implementation of the PRISMA ISD system in Québec
Hébert R, Veil A, Raîche M, Dubois M-F, Dubuc N, Tousignant M
Components: The six components of the PRISMA model will be presented. The model was implemented in three areas (urban, rural with or without a local hospital) in Québec, Canada and the 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 different organizations of the network shows that most interactions are perceived at the cooperation level and some getting to the highest collaboration level. The perception of efficacy of case managers was very high. Implementing such model is feasible and decision to generalize it was made in Québec.
2. Population impact of PRISMA on frail older people and utilization of health and social services
Hébert R, Raîche M, Dubois M-F, Gueye NR, Dubuc N, Tousignant M
Objective: The objective of the population impact study was to evaluate the impact of the PRISMA model on health, satisfaction and services utilization of frail older people. It was a population-based study with a quasi-experimental design. From a random selection of people over 75 years old, a sample of 1501 persons identified at risk of functional decline was recruited in the three experimental areas (n=751) and three comparison zones (n=800). Subjects were measured at baseline and yearly for four years on functional autonomy, satisfaction with services and empowerment. Functional decline was defined as a loss of five points on the SMAF disability scale, institutionalization or death. Information on utilization of health and social services (public, private and community) was collected by bi-monthly phone questionnaires.
Results: When the last two years (where implementation rate was over 75%) were compared with first two years, the experimental group presented a difference of 6.3% on functional decline prevalence (p=0.03). Satisfaction and empowerment were significantly higher (both p<0.001) in the experimental group. For health services utilization, a 20% reduction of visits to emergency room (p<0.001) was observed in the experimental cohort. The hospitalization rate was also lower in the experimental group but the difference was not statistically significant (p=0.19). No significant effect was observed on other services.
3. Efficiency of the PRISMA model regarding population impacts
Durand S, Hébert R, Blanchette D, Buteau M
Efficiency: Assessing the efficiency of PRISMA is based on a comprehensive economic evaluation, with a societal approach. Given the implementation complexity of the six components in this innovative integration model, a micro-analysis was performed to assess its implementation and operational costs for the three experimental areas. The impact on residential, health and social services expenditures was also valued, based on use data collected during bimonthly interviews. Unit costs of these numerous services were estimated according to the opportunity cost approach. All these economic data were compared with the results of the population impact study through a cost-consequences analysis in order to measure PRISMA efficiency.
Results: The overall cost was not higher in the experimental group. It seems that implementation and operational costs of the PRISMA were offset relatively quickly by the savings likely stemming from better-adapted services. Also, the PRISMA had no effect on the mix of public, private and community costs. The population impact study showed positive impacts on functional decline prevalence, on handicaps, and on older people's satisfaction and empowerment. The only negative impact on the population is caregiver burden. Overall, these findings add evidence in support of increased efficiency under PRISMA.
4. Poster abstract: the PRISMA France study: implementation rate and factors influencing this rate
Somme D, Trouve H, Etheridge F, Gagnon D, Couturier Y, Balard F, Saint-Jean O
See elsewhere in this supplement.
PMCID: PMC2807086
PRISMA model; integrated service delivery
19.  You want us to manage cases, never! Love, hate and paradoxes of the relationship of social workers with the notion of case management 
Purpose
This communication concerns the renewal of case management in favour of the aspiration to link management and intervention in a services' integration device. Three main sections are encompassed in this communication. The first consists of a brief presentation of the history and foundations of case management, the second of an analysis of the receptiveness of the primary-adoptants of a pilot-study in France to a Quebecois case management model and the last of a proposition to reproblematize questions concerning the relation between management and intervention.
Methods
This presentation is based upon a transversal observation of results of qualitative studies concerning the reception of the notion of case management by social workers. The data were composed of discursive material collected from three studies (two from Québec and one from France) with social workers who recently engaged in case management.
Results and conclusions
Even though case management arose from the patrimony of social work, its renewal raises concerns in terms of rationalization, medicalization and systematization of the discipline. These fears are partly compensated by the hope that this new function will allow social workers to base their interventions with complex clinical cases on an interdisciplinary solidarity.
PMCID: PMC2807070
case management; social workers
20.  Institutional integration, health and social care policy and social welfare: an application of the ‘path dependence’ theory in France 
Introduction
The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. The PRISMA France study aims to investigate the implementation of this model, which relies on the establishment of advisory boards at institutional, organisational and professional levels of decision-making, in France. These boards are guided by whole systems thinking and function in a joined-up, co-ordinated manner.
Method
A qualitative approach was adopted to study the model's implementation. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings and administrative documentations. Validity was insured by triangulation methods and content saturation.
Results
Our analyses revealed the complexity, instability and fragmentation of the institutional governance of publics policies for elderly people. The ‘path dependence’ to the Bismarckian system and the incomplete reforms of gerontological policies generate a cohabitation of three concurrent policies (national, regional and local) and a juxtaposition of two institutional systems (health and social care policy and social welfare). In such a context, no institution possesses sufficient authority to determine gerontological policy.
Conclusion
In the light of these analyse, the particularly complex and time-consuming implementation of the PRISMA model in France can be better understood.
PMCID: PMC2807065
path dependency; public policies; integrated health care networks; France
21.  The PRISMA France study: implementation rate and factors influencing this rate 
Introduction
The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. In the PRISMA-France study, we qualitatively studied the implementation process of this model in French settings.
Method
Our analyses were based on in-depth interviews, meeting observations and the documentation produced.
Results
We adapted the implementation scale inherent to the PRISMA model to fit the French context and, using this scale, were able to appreciate a 15% progression of implementation, from 5% to 20%, in the first 18 months of the study. The factors that contributed to this rate of progression are of three main types. To begin with, contextual factors intrinsic to the French setting complexified the incorporation of integration into the public policy agenda and the means to achieve this feat. Secondly, factors related to the background of the concerned managers and professionals were identified. Thirdly, factors related to the particularities of the PRISMA-Experiment's governance were noted. Our experience leads to consider time as the answer to these hindering contextual, professional and governance issues.
Conclusion
These observations hold an important strategic value in a time where a wider integration experimentation is planned by the ‘plan-Alzheimer’ in France.
PMCID: PMC2807061
integration measurement; factors influencing implementation; integrated health care networks; France
22.  Effect of Alerts for Drug Dosage Adjustment in Inpatients with Renal Insufficiency 
Objectives
Medication errors constitute a major problem in all hospitals. Between 20% and 46% of prescriptions requiring dosage adjustments based on renal function are inappropriate. This study aimed to determine whether implementing alerts at the time of ordering medication integrated into the computerized physician order entry decreases the proportion of inappropriate prescriptions based on the renal function of inpatients.
Design
Six alternating 2-month control and intervention periods were conducted between August 2006 and August 2007 in two medical departments of a teaching hospital in France. A total of 603 patients and 38 physicians were included. During the intervention periods, alerts were triggered if a patient with renal impairment was prescribed one of the 24 targeted drugs that required adjustment according to estimated glomerular filtration rate (eGFR).
Measurements
The main outcome measure was the proportion of inappropriate first prescriptions, according to recommendation.
Results
A total of 1,122 alerts were triggered. The rate of inappropriate first prescriptions did not differ significantly between intervention and control periods (19.9% vs. 21.3%; p = 0.63). The effect of intervention differed significantly between residents and senior physicians (p = 0.03). Residents tended to make fewer errors in intervention versus control periods (Odds ratio 0.69; 95% confidence interval 0.41 to 1.15), whereas senior physicians tended to make more inappropriate prescriptions in intervention periods (odds ratio 1.88; 95% confidence interval 0.91 to 3.89).
Conclusion
Alert activation was not followed by a significant decrease in inappropriate prescriptions in our study. Thus, it is still necessary to evaluate the impact of these systems if newly implemented in other settings thanks to studies also designed to watch for possible unanticipated effects of decision supports and their underlying causes.
doi:10.1197/jamia.M2805
PMCID: PMC2649320  PMID: 19074305
23.  The individualized service plan as a clinical integration tool: qualitative analysis in the Quebec PRISMA experiment 
Introduction
One aspect of clinical integration involves case managers' tools and particularly the individualized service plan.
Methods
We examined individualized service plan content and use in the PRISMA experiment. We analyzed 50 charts, and conducted and recorded interviews regarding individualized service plan use with all the case managers concerned (n=13).
Results
Delays between starting case management and writing the individualized service plan were long and varied (0–596 days, mean: 117 days). During the interviews, the individualized service plan was described as the ‘last step’ once the active planning phase was over. The reasons for formulating plans were mainly administrative. From a clinical viewpoint, individualized service plans were used as memoranda and not to describe services (842 interventions not mentioned in the plans) or needs (694 active problems not mentioned). Case managers felt uncomfortable with the individualized planning task and expected a tool more adapted to their needs.
Conclusion
Although a majority of the case managers' charts contained an individualized service plan, implementation of this tool seems tenuous. Because of the discrepancy between the potential usefulness expected by case managers and their actual use, a working committee was created to develop proposals for modifying the instrument.
PMCID: PMC2690906  PMID: 19503736
case management tool; individualized service plan; clinical integration; gerontology; qualitative research

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