Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: an implementation and realist evaluation protocol

INTRODUCTION

Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada.

METHODS AND ANALYSIS

We will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method.

ETHICS AND DISSEMINATION

This study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.

How primary health care teams perceive the integration of oral health care into their practice: A qualitative study

Recently, new models for the integration of oral health into primary care have been proposed. However, these models may be adopted by a variety of health care systems, and will reach successful outcomes only if they can be adapted to suit the local context. To this end, the objective of this study was to explore the perceptions of Quebec primary health care teams on the integration of oral health into primary care. A qualitative approach and interpretive description methodology were used to conduct the study within a case-study design. Purposeful sampling with maximum variation and snowball technique were used for recruitment of study participants. Seventy-four in-depth, semi-structured interviews and five focus groups were conducted with primary health care teams including health care providers and managers working in a rural and an urban health care center. The interview guide and study conceptual framework were based on the Rainbow model. Data collection and data analyses were conducted concurrently and continued until saturation was achieved. To analyze the data, four phases of qualitative analysis were followed. The thematic analysis included interview debriefing, transcript coding, data display, and interpretation. Data analysis was conducted both manually and with the use of Atlas-ti software. A total of four themes emerged from the interviews and focus group discussions. These themes covered all domains of the study theoretical model and included: 1) drivers of integration; 2) importance of integration; 3) professionals’ role in integrated care; and 4) barriers and enablers of integration. In general, most of the barriers expressed by study participants were related to the organizational and system domains of integration. Primary health care teams who provide care in rural and urban areas in Quebec expressed their concerns on the absence of integrated oral health services. Implementation of governance policies, the prioritization of educational and management measures as well as inter-professional collaboration toward innovative care models could facilitate this integration.

Looking for capacities rather than vulnerabilities: The moderating effect of health assets on the associations between adverse social position and health

To increase capacities and control over health, it is necessary to foster assets (i.e. factors enhancing abilities of individuals or communities). Acting as a buffer, assets build foundations for overcoming adverse conditions and improving health. However, little is known about the distribution of assets and their associations with social position and health. In this study, we documented the distribution of health assets and examined whether these assets moderate associations between adverse social position and self-reported health. A representative population-based cross-sectional survey of adults in the Eastern Townships, Quebec, Canada (n = 8737) was conducted in 2014. Measures included assets (i.e. resilience, sense of community belonging, positive mental health, social participation), self-reported health (i.e. perceived health, psychological distress), and indicators of social position. Distribution of assets was studied in relation to gender and social position. Logistic regressions examined whether each asset moderated associations between adverse social position and self-reported health. Different distributions of assets were observed with different social positions. Women were more likely to participate in social activities while men were more resilient. Resilience and social participation were moderators of associations between adverse social position (i.e. living alone, lower household income) and self-reported health. Having assets contributes to better health by increasing capacities. Interventions that foster assets and complement current public health services are needed, especially for people in unfavorable situations. Health and social services decision-makers and practitioners could use these findings to increase capacities and resources rather than focusing primarily on preventing diseases and reducing risk factors.

Providers' Perspectives on the Implementation of Mandated Local Health Networks for Older People in Québec

INTRODUCTION

In many countries, integrated care has been implemented to improve the quality, efficiency and patient experience of services. Understanding how integrated care is adopted in different settings may give insights into where, how and why different components of the organisational design work. The aim of this article is to understand how and why integrated care for older people has been implemented in different contexts from the perspective of providers.

THEORY AND METHODS

The study uses an innovative composite framework for the implementation of integrated care models, which posits that structural, organisational, provider, innovation and patient factors influence implementation along six dimensions of integration. A qualitative multiple case study was done of three cases in Québec using document analysis and semi-structured interviews of 28 providers. Descriptive comparisons and thematic analysis were performed.

RESULTS

Providers considered that structural (government policy) and organisational (mergers) factors highly influenced the implementation of organisational and functional dimensions of integration, at the detriment of clinical integration. Provider, innovation and patient factors mildly or moderately influenced the implementation of integration.

CONCLUSION

Structural and organisational factors were necessary conditions for the implementation of administrative components of integration, with great variability in the implementation of some clinical components.

Reorganising health and social care in Québec: a journey towards integrating care through mergers

Context

Two reforms (2014, 2015) characterised by the merger of public health care establishments profoundly shaped the current organisation of Quebec’s healthcare system. In 2015, 22 megastructures called Integrated Health and Social Services Centres/Integrated University Health and Social Services Centres (IHSSC/IUHSSC), were created and mandated to organise care delivery to their local populations.

Objective

To describe the service configuration of the 2015 healthcare system reforms, emphasising on how it shaped the organisation of primary health care (PHC) in Quebec.

Results

With the creation of IHSSCs/IUHSSCs, Quebec’s healthcare system passed from three to two levels of governance, leading to a centralisation of decision-making powers. Most health services are delivered by the new organisations, while most PHC is delivered by semi-private medical practices, mainly Family Medicine Groups (FMGs). The FMG model is the preferred strategy to develop interdisciplinary team-work and inter-organizational collaborations with other PHC services.

Conclusion

mechanisms through which centralised healthcare systems achieve community oriented integrated care (COIC) need to be properly understood in order to improve meaningful clinical outcomes. Mergers may not sufficiently achieve integration of services in all its dimensions. These reforms should be monitored and evaluated on their capacity to mobilise all providers as well as physicians to participate in COIC.

From theoretical concepts to policies and applied programmes: the landscape of integration of oral health in primary care

BACKGROUND

Despite its importance, the integration of oral health into primary care is still an emerging practice in the field of health care services. This scoping review aims to map the literature and provide a summary on the conceptual frameworks, policies and programs related to this concept.

METHODS

Using the Levac et al. six-stage framework, we performed a systematic search of electronic databases, organizational websites and grey literature from 1978 to April 2016. All relevant original publications with a focus on the integration of oral health into primary care were retrieved. Content analyses were performed to synthesize the results.

RESULTS

From a total of 1619 citations, 67 publications were included in the review. Two conceptual frameworks were identified. Policies regarding oral heath integration into primary care were mostly oriented toward common risk factors approach and care coordination processes. In general, oral health integrated care programs were designed in the public health sector and based on partnerships with various private and public health organizations, governmental bodies and academic institutions. These programmes used various strategies to empower oral health integrated care, including building interdisciplinary networks, training non-dental care providers, oral health champion modelling, enabling care linkages and care coordinated process, as well as the use of e-health technologies. The majority of studies on the programs outcomes were descriptive in nature without reporting long-term outcomes.

CONCLUSIONS

This scoping review provided a comprehensive overview on the concept of integration of oral health in primary care. The findings identified major gaps in reported programs outcomes mainly because of the lack of related research. However, the results could be considered as a first step in the development of health care policies that support collaborative practices and patient-centred care in the field of primary care sector.

Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol

INTRODUCTION

Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers).

METHODS AND ANALYSIS

This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders).

ETHICS AND DISSEMINATION

This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network.

PROSPERO REGISTRATION NUMBER

CRD42015020558.

Barriers and facilitators in the integration of oral health into primary care: a scoping review

OBJECTIVE

This scoping study has been conducted to map the literature and provide a descriptive synthesis on the barriers and facilitators of the integration of oral health into primary care.

METHODS

Grounded in the Rainbow conceptual model and using the Levac et al six-stage framework, we performed a systematic search of electronic databases, organisational websites and grey literature from 1978 to April 2016. All publications with a focus on the integration of oral health into primary care were included except commentaries and editorials. Thematic analyses were performed to synthesise the results.

RESULTS

From a total of 1619 citations, 58 publications were included in the review. Barrier-related themes included: lack of political leadership and healthcare policies; implementation challenges; discipline-oriented education; lack of continuity of care and services and patients' oral healthcare needs. The facilitators of integration were supportive policies and resources allocation, interdisciplinary education, collaborative practices between dental and other healthcare professionals, presence of local strategic leaders and geographical proximity.

DISCUSSION AND PUBLIC HEALTH IMPLICATIONS

This work has advanced the knowledge on the barriers and facilitators at each integration domain and level, which may be helpful if the healthcare organisations decide to integrate oral health and dental services into primary care. The scoping review findings could be useful for both dental and medical workforce and allied primary healthcare providers. They could also guide the development of healthcare policies that support collaborative practices and patient-centred care in the field of primary care.

How do Policy and Institutional Settings Shape Opportunities for Community-Based Primary Health Care? A Comparison of Ontario, Québec and New Zealand

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the 'space available' for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the 'barbed-wire fence' that separates funding of medical and 'non-medical' primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence.

Implementing Community Based Primary Healthcare for Older Adults with Complex Needs in Quebec, Ontario and New-Zealand: Describing Nine Cases

The aim of this paper is to set the foundation for subsequent empirical studies of the "Implementing models of primary care for older adults with complex needs" project, by introducing and presenting a brief descriptive comparison of the nine case studies in Quebec, Ontario and New Zealand. Each case is described based on key dimensions of Rainbow model of Valentijn and al (2013) with a focus on "meso level" integration. Meso level integration is represented by organizational and professional elements of the Rainbow Model, which are of particular interest in our nine case studies. Each of the three cases in Ontario and three in New Zealand are different and described separately. In Quebec, a local health services network model is presented across the three cases studied with variations in the way it is implemented. The three cases selected in the three jurisdictions under study were not chosen to be representative of wider practice within each country, but rather represent interesting and unique models of community-based primary healthcare integration. Similarities and variations in the integrated care models, context and dimension of integration offer insights regarding core component of integration of services, offering a foundational understanding of the cases on which future analysis will be based.

Capturing how age-friendly communities foster positive health, social participation and health equity: a study protocol of key components and processes that promote population health in aging Canadians

BACKGROUND

To address the challenges of the global aging population, the World Health Organization promoted age-friendly communities as a way to foster the development of active aging community initiatives. Accordingly, key components (i.e., policies, services and structures related to the communities' physical and social environments) should be designed to be age-friendly and help all aging adults to live safely, enjoy good health and stay involved in their communities. Although age-friendly communities are believed to be a promising way to help aging Canadians lead healthy and active lives, little is known about which key components best foster positive health, social participation and health equity, and their underlying mechanisms. This study aims to better understand which and how key components of age-friendly communities best foster positive health, social participation and health equity in aging Canadians. Specifically, the research objectives are to: 1) Describe and compare age-friendly key components of communities across Canada 2) Identify key components best associated with positive health, social participation and health equity of aging adults 3) Explore how these key components foster positive health, social participation and health equity METHODS: A mixed-method sequential explanatory design will be used. The quantitative part will involve a survey of Canadian communities and secondary analysis of cross-sectional data from the Canadian Longitudinal Study on Aging (CLSA). The survey will include an age-friendly questionnaire targeting key components in seven domains: physical environment, housing options, social environment, opportunities for participation, community supports and healthcare services, transportation options, communication and information. The CLSA is a large, national prospective study representative of the Canadian aging population designed to examine health transitions and trajectories of adults as they age. In the qualitative part, a multiple case study will be conducted in five Canadian communities performing best on positive health, social participation and health equity.

DISCUSSION

Building on new and existing collaborations and generating evidence from real-world interventions, the results of this project will help communities to promote age-friendly policies, services and structures which foster positive health, social participation and health equity at a population level.

A scoping review protocol on social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness

INTRODUCTION

Indigenous elders have traditionally played an important role in maintaining social cohesion within their communities. Today, part of this role has been taken over by government social and healthcare services, but they are having limited success in addressing social challenges. Increasing elders' social participation and intergenerational solidarity might foster community development and benefit young people, families, communities and the elders themselves. However, knowledge of the contribution of elders' social participation and intergenerational solidarity to wellness is scattered and needs to be synthesised. This protocol presents a scoping review on the social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness.

METHODS AND ANALYSIS

This scoping review protocol is based on an innovative methodological framework designed to gather information from the scientific and grey literature and from indigenous sources. It was developed by an interdisciplinary team including indigenous scholars/researchers, knowledge users and key informants. In addition to searching information databases in fields such as public health and indigenous studies, an advisory committee will ensure that information is gathered from grey literature and indigenous sources.

ETHICS

The protocol was approved by the Ethics Review Board of the Université du Québec en Abitibi-Témiscamingue and the First Nations of Quebec and Labrador Health and Social Services Commission.

DISCUSSION

The comprehensive synthesis of the scientific and grey literature and indigenous sources proposed in this protocol will not only raise awareness within indigenous communities and among healthcare professionals and community organisations, but will also enable decision-makers to better meet the needs of indigenous people.

CONCLUSION

The innovative methodological framework proposed in this scoping review protocol will yield richer information on the contribution of elders to community wellness. This work is an essential preliminary step towards developing research involving indigenous communities, drawing on the social participation of elders and intergenerational solidarity.

Integration of oral health into primary care: a scoping review protocol

INTRODUCTION

Integrated care has been introduced as a means of improving health outcomes and access to care, and reducing the cost of healthcare. Despite its importance, the integration of oral health into primary care is still an emerging healthcare pathway. This scoping review protocol has been developed and funded by the Canadian Institutes of Health Research to provide an evidence-based synthesis on a primary oral healthcare approach and its effectiveness in improving oral health outcomes.

METHODS AND ANALYSIS

The 6-stage framework developed by Levac et al underpins this scoping review. We will identify relevant existing theories, programmes and original research through a comprehensive and systematic search of electronic databases such as OVID (MEDLINE, EMBASE, Cochrane databases), NCBI (PubMed), EBSCOhost (CINAHL), ProQuest, Databases in Public Health, Databases of the National Institutes of Health (health management and health technology) and relevant organisational websites and other sources of grey literature. All types of studies from 1978 to May 2016 in the French and English languages will be included. Using the Rainbow conceptual model of integrative primary care, a qualitative descriptive approach and thematic analysis will be used to synthesise the literature. Implementing novel healthcare models necessitates identifying barriers, sharing knowledge and delivering information. The integration of oral healthcare into primary care is an approach that promotes breaking the boundaries separating oral healthcare professionals and primary care. It creates opportunities for the dental workforce to become more involved in community-based practice and to assume shared responsibility with healthcare professionals to address the unmet oral health needs of those experiencing vulnerability and marginalisation.

ETHICS AND DISSEMINATION

The scoping study has received approval from the Université de Montréal's Institutional Review Board (#14-097-CERES-D). The findings will be disseminated through publications and presentations in provincial, national and international research symposiums and professional meetings.

Personalized citizen assistance for social participation (APIC): A promising intervention for increasing mobility, accomplishment of social activities and frequency of leisure activities in older adults having disabilities

BACKGROUND

Social participation, a determinant of health in older adults, requires innovative interventions. The personalised citizen assistance for social participation (APIC) involves weekly three-hour personalised stimulation sessions targeting significant social and leisure activities difficult to accomplish. Recently adapted for older adults, the APIC's impact on this population is unknown.

OBJECTIVE

This study explored the impact of APIC on older adults with disabilities.

METHODS

A mixed-method design including a pre-experimental component was used with 16 participants (11 women) aged 66-91 (79.4±8.7) with disabilities, living at home. They completed functional autonomy, social participation, leisure and quality of life questionnaires, and semi-structured interviews.

RESULTS

APIC increased older adults' functional autonomy (p=0.02), accomplishment (p<0.01) and satisfaction (p=0.02) with social participation, and frequency of leisure practice (p<0.01). Post-intervention, participants wished to modify the practice (p<0.01) and frequency (p<0.01) of leisure activities, and difficulties in their social environment diminished (p=0.03). Their attitude toward leisure (p=0.04) as well as their health (p<0.01) and psychological (p=0.03) quality of life improved. Older adults thought APIC helped them resume, maintain, explore and experiment with significant social activities. It also increased their psychological and physical well-being, feeling of control, connectedness, self-esteem and motivation to accomplish activities. Finally, APIC can compensate for an unavailable and crumbling social network.

CONCLUSION

APIC is a promising intervention that leads to new opportunities for older adults to increase community integration and enhance the social component of their lives. It can also optimise how the needs of older adults are met, including utilisation of personal and environmental resources.

[New professional field in France: Analysis of the training needs of case managers]

Case management is a relatively new career field in France. It was first introduced on an experimental basis in 2007-2008, and was then developedfollowing the National Alzheimer Plan and finally enshrined in legislation in 2012. This careerfield is based on a set of tasks widely described internationally: identifying the right level of intervention, standardized multidimensional assessment, planning all aid (care and social services), implementation of the plan, monitoring and reassessment and periodic reassessment of all needs in a continuous and long-term process. The specific, systematic and dedicated nature of these tasks to these tasks makes training essential. Regulations also stipulate that the professional must acquire additional training by a dedicated inter-university degree. This requirement is a French specificity The authors present the history of case management and training in France and analyze the various international training frameworks identified by an Internet search. Moreover, based on the opinions expressed by case managers at different times of the scientific assessment and a review ofseveral studies conducted by inter-university case management program students, this article highlights the specific training needs of case managers and how the proposed training can meet these needs.

The relevance of positive approaches to health for patient-centered care medicine

Over the last centuries, the field of medicine has evolved from a disease-oriented model where individuals were seen as simple hosts for diseases, to a patient-centered approach where health professionals actively try to engage their patients in treatment decision-making. This deep change in models of care acknowledges that patients are important actors in health fulfillment. Even though this change in models of care was a major step forward for medical practices and treatment success, patient-centered care medicine (PCCM) has brought its own limitations. In this brief comment, the concept of PCCM will be defined and the benefits of this model of care will be highlighted. The limitations inherent to PCCM will also be summarized. A discussion on how PCCM can move forward will be undertaken using evidence-based knowledge on positive approaches to health. Finally, an encompassing perspective (i.e. the salutogenic perspective) will il lustrate how the PCCM model of care can help to operationalize major health conceptual frameworks worldwide.

L’appropriation par les primo-adoptants de l’Approche École en santé au Quebec

L’ Approche École en santé (AÉS) est une approche globale de promotion de la santé inspirée des principes des « Health Promoting Schools » (écoles promotrices de santé). L’AÉS est associée à un dispositif d’accompagnement des écoles volontaires pour l’implanter qui comporte des ressources professionnelles d’accompagnement et divers outils. Le présent article rend compte des résultats d’une recherche qualitative portant sur l’appropriation locale de cette approche par des écoles ayant participé à la première vague d’implantation au Québec. Après avoir exposé le contexte, la méthodologie et le cadre théorique de l’étude, nous présenterons les appropriations locales observées, et ce qui semble les avoir conditionnées, du point de vue des acteurs.