V1SAGES

Date

2012-2015

Partners

Pfizer-FRQS-MSSS Grant
Saguenay-Lac-Saint-Jean regional health authority

Aim

Evaluate the implementation of case management by a family medicine group (FMG) nurse and self-management support groups for FMG patients with complex needs.

Articles and posters

Protocol

• Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial

Results

• Case management in primary care for frequent users of health care services with chronic diseases: A qualitative study of patient and family experience
• The Chronic Disease Self-Management Program: the experience of frequent users of health care services and peer leaders
• The relationship between health literacy and quality of life among frequent users of health care services: a cross-sectional study
• The relationship between health literacy and patient activation among frequent users of healthcare services: a cross-sectional study
• Case management in primary care for frequent users of health care services: A mixed methods study

Scientific posters

• Chronic Diseases, Vulnerability and Frequent Use of Hospital Services: Insight into the Pre-Implementation Evaluation of an Intervention in Primary Care. North American Primary Care Research Group (NAPCRG) annual conference 2013.
• Case Management and Self-Management Support for Frequent Hospital Services Users with Chronic Disease in Primary Care: Research Protocol of a Pragmatic Intervention. North American Primary Care Research Group (NAPCRG) annual conference 2013.
• Case management and self-management support in primary care for individuals with chronic diseases who are frequent users of health services: A pre-implementation evaluation. Canadian Association for Health Services and Policy Research (CAHSPR) annual conference 2013.
• Action Learning to Support the Development of Primary Care Nurses in the Case Management of Patients with Chronic Diseases, Frequent Users of Hospital Services. North American Primary Care Research Group (NAPCRG) annual conference 2014.
• The relationship between health literacy and patient activation or quality of life among frequent users of primary care. North American Primary Care Research Group (NAPCRG) annual conference 2014.
• Complex patients: what is associated with frequent use of healthcare services? North American Primary Care Research Group (NAPCRG) annual conference 2014.
• High users of hospital services referred to a case management intervention in primary care: Who are they?  Health Services Research Network (HSRN) conference 2014.
• Projet V1SAGES: Gestion de cas et de soutien à l’autogestion en GMF pour les grands utilisateurs de services hospitaliers. 5e Rendez-vous de la gestion des maladies chroniques 2014. (French only)
• The Chronic Disease Self-Management Program in primary care for frequent users of healthcare services: implementation issues. North American Primary Care Research Group (NAPCRG) annual conference 2015.
• V1SAGES – Implantation et évaluation pragmatique d’une intervention en gestion de cas et de soutien à l’autogestion pour les personnes atteintes de maladies chroniques vulnérables en première ligne. Journée scientifique du Réseau-1 2015. (French only)
• V1SAGES – Implantation et évaluation pragmatique d’une intervention de gestion de cas et de soutien à l’autogestion pour les personnes grandes utilisatrices de services atteintes de maladies chroniques en première ligne. Conférence du Fond de recherche du Québec – Santé (FRQS) 2016. (French only)

Results

Case management by an FMG nurse improved the integration of care based on patient experience, reduced psychological distress and improved the sense of safety of patients and their families. Participants in self-management support groups reported an overall improvement in their self-management skills.

Team

Principal investigators

Catherine Hudon, Professor, Department of Family Medicine and Emergency Medicine, Université de Sherbrooke

Maud-Christine Chouinard, Professor, Faculty of Nursing, Université de Montréal

Co-investigators

Christine Loignon, Professor, Department of Family Medicine and Emergency Medicine, Université de Sherbrooke

Marie-France Dubois, Professor, Department of Community Health Sciences, Université de Sherbrooke

Pasquale Roberge, Professor, Department of Family Medicine and Emergency Medicine, Université de Sherbrooke

Éric Tchouaket, Professor, Department of Nursing, Université du Québec en Outaouais

Research and project coordinators

Danielle Bouliane, Research Coordinator, Saguenay-Lac-Saint-Jean regional health authority

Madone Turcotte, Project Coordinator, Saguenay-Lac-Saint-Jean regional health authority

Research assistants

Fatoumata Diadiou, Saguenay-Lac-Saint-Jean regional health authority

Mireille Lambert, Saguenay-Lac-Saint-Jean regional health authority

Decision makers and managers

Donald Aubin, Director of Health Services, Medical and University Affairs, Saguenay-Lac-Saint-Jean regional health authority

Isabelle Boulianne, Manager, Chicoutimi FMG

Marcel Fortin, Physician in Charge, Lac-Saint-Jean-Est FMG – Métabetchouan Clinic

Serge Lavoie, Director of client programs and front-line services, Chicoutimi health authority

Daniel Olivier, Director of Physical Health Programs and Hospital Services, Lac-Saint-Jean-Est health authority

Lorraine Richard, Physician in charge, des Rivières FMG – Barrette Medical Clinic

Guy Verreault, Physician in Charge, Alma FMG

Clinicians

Maya Beaudry, Nurse Case Manager, des Rivières FMG – Barrette Medical Clinic

Myriam-Nicole Bilodeau, Social Worker Coordinator of the Arrimage Program, Chicoutimi health authority

Valérie Boivin, Nurse Case Manager, Alma FMG

Annie Côté, Physician, Chicoutimi FMG

Pascale Desbiens, Lac-Saint-Jean-Est FMG – Métabetchouan Clinic

Marie-Hélène Doucet, Nurse Case Manager, des Rivières FMG – Barrette Medical Clinic

Maxime Fortin, Nurse Case Manager, Alma FMG

Julie Godbout, Nurse Case Manager, Chicoutimi FMG

Julie Guay, Nurse Manager, Alma FMG

Isabelle Tremblay, Community Pharmacist, Chicoutimi health authority

Patient partners 

Daniel Larouche

Réjean Leblanc