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. 2014 Apr;48(2):357–365. doi: 10.1590/S0034-8910.2014048004941

Table.

Characteristics of the models of integrated and coordinated care networks for older adults.

Model Structure Processes Results
SIPA1,2 ER and hospital, institutionalization and palliative care. General practitioner and specialists, home care, sheltered housing, "hospital dia" and "day center". Triage for frailty confirmed by functional assessment. Higher community spending, lower institutional spending, increased user and carer satisfaction. Main impact: freeing up hospital beds previously occupied by patients awaiting.
PACE10,32 Day center (centralizes medical and social services and functions as a residence) pays for services it does not have. Medical and social services with support from an interdisciplinary team. The team manages the case. Greater use of outpatients, less hospital use, less time in nursing homes. Better perceived health, quality of life, satisfaction with care and better perception of functional state.
PRISMA13 Home Care, hospital services, hospital dia, day center, social services, voluntary support including providing meals in the home and community transport. Single entry point, triage of frailty risk confirmed by functional assessment, case manager, care plan, computerized medical records. Less hospital use, increased patient and carer satisfaction with care received.
Guided Care5-7,15,20 Trained nursing, GP, multidisciplinary team and computerized medical records. Comprehensive geriatric assessment, care plan, case management, carer support. Less use of in-home, hospital and specialist nursing services. Families spending less, less functional loss and better perceived health.
Grace12,13 Multi-specialties center, acute care unit, specialized nursing and physician house call program. One computerized medical record integrates patient to local health care services. Triage of risk, comprehensive geriatric assessment, care plan and case management. Less use of ER. Patients identified as at greater risk made less use of ER, hospital and hospital dia.