V1SAGES 2: Partners for an Optimal Organization of the Continuum of Care for Frequent Users of Health and Social Services
Date
2014-2018
Partners
Canadian Institutes of Health Research (CIHR)
Fonds de recherche du Québec en santé (FRQS)
Saguenay-Lac-Saint-Jean regional health authority (CIUSSS)
Fondation de Ma Vie
MediaMed Technologies
Aim
The purpose of this project was to describe a harmonized model of case management based on the evaluation of case management programs deployed in six facilities of Saguenay-Lac-Saint-Jean regional health authority (CIUSSS) to improve these programs while creating new case management knowledge that could be useful in other contexts.
Articles, presentations and posters
Protocol
Results
- Case management programs for improving integrated care for frequent users of healthcare services: an implementation analysis.
- Evaluating complex interventions in real context: Logic analysis of a case management program for frequent users of healthcare services
- Logic model of a case management program in primary care for frequent users of healthcare services
Scientific presentations
- Case management for frequent users of healthcare services: a logic model presenting links between resources, activities and outcomes. Canadian Association for Health Services and Policy Research (CAHSPR) annual conference 2019.
- Implementation analysis of case management programs for frequent users of healthcare services: a multiple embedded case study. North American Primary Care Research Group (NAPCRG) annual conference 2020.
Scientific posters
- Case management program for frequent users of healthcare services: an implementation analysis. North American Primary Care Research Group (NAPCRG) annual conference 2019.
- Evaluating complex interventions: Logic analysis of a case management program for frequent users of healthcare services. North American Primary Care Research Group (NAPCRG) annual conference 2019.
Results
Case management programs help improve the integration of care and services. The skills, leadership and experience of the case manager, providers’ access to the individualized service plan (ISP), the consideration of patient and family members’ needs and their participation in decision-making, and the provision of self-management support have an impact on integrated care and health service utilization.
The study highlights the importance of tailoring the trajectory and the intensity of intervention to the degree of complexity of the patients. A harmonized model of case management (logic model) was developed by the research team in close collaboration with decision makers, so that they can better understand the causal links between the context where the case management program was implemented, the resources dedicated to it, the performed activities, and the expected outcomes for both patients and the healthcare system. Thus, informed adaptations can be made in a continuous improvement perspective.
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
Astrid Brousselle, Professor, School of Public Administration, University of Victoria
Marie-France Dubois, Professor, Department of Community Health Sciences, Université de Sherbrooke
Christine Loignon, Professor, Department of Family Medicine, Université de Sherbrooke
Pierre Pluye, Professor, Department of Family Medicine, McGill University
Pasquale Roberge, Professor, Department of Family Medicine, Université de Sherbrooke
Charo Rodriguez, Professor, Department of Family Medicine, McGill University
Collaborator
Trobias Freund, Consultant, Competence Centre of General Practice, Department of General Practice and Health Services Research, University Hospital Heidelberg
Research coordinators
Danielle Bouliane, Saguenay–Lac-Saint-Jean regional health authority
Mireille Lambert, Saguenay–Lac-Saint-Jean regional health authority
Research assistants
Mathieu Bisson, University of Sherbrooke
Fatoumata Diadiou, Saguenay–Lac-Saint-Jean regional health authority
Decision makers and managers
Myriam-Nicole Bilodeau, Coordinator of the Continuum of Care, Head of the Chronic Diseases Department, Saguenay-Lac-Saint-Jean regional health authority
Martine Couture, Director General President (2014-2019), Saguenay-Lac-Saint-Jean regional health authority
Camil Dion, Executive Director, Lac-Saint-Jean Est health authority (until 2015)
Gilles Gagnon, Director General, Chicoutimi health authority (until 2015)
Antoine Groulx, Director of the organization of integrated front-line services, Ministère de la Santé et des Services sociaux – Québec
Régis Harvey, Director General, Jonquière health authority (until 2015)
Julie Labbé, President and CEO, Saguenay-Lac-Saint-Jean regional health authority
Sylvie Massé, Director of Nursing, Saguenay-Lac-Saint-Jean regional health authority
Jean Mireault, President of MediaMed Technologies
Jean Morneau, Director of Teaching, Research and Innovation, Director of Nursing, Saguenay-Lac-Saint-Jean regional health authority
Martine Nepton, Executive Director, Cléophas-Claveau health authority (until 2015)
Mélanie Paradis, Director of Nursing, Saguenay-Lac-Saint-Jean regional health authority
Caroline Savard, Coordinator of Continuum of Care Programs, Assistant to the Director of Nursing, Saguenay-Lac-Saint-Jean regional health authority
Marc Villeneuve, Coordinator of Ambulatory Services, Saguenay-Lac-Saint-Jean regional health authority
Clinicians
Dr. Eva Marjorie Couture, Chicoutimi FMG, and Graduate student, Health Sciences, University of Sherbrooke
Marie-Ève Bergeron, Case Manager, Chicoutimi health authority
Marc Bolduc, Case Manager, Roberval health authority
Audrey Corneau, Case Manager, Chicoutimi health authority
Sylvain Gagnon, Case Manager, Cléophas-Claveau health authority
Julie Godbout, Case Manager, Chicoutimi health authority
Cécilia Ruiz, Case Manager, Jonquière health authority
Patient partners
Gilles Gauthier
Véronique Sabourin
Claude Spence
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