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.

Explaining the success or failure of quality improvement initiatives in long-term care organizations from a dynamic perspective

The purpose of this study was to better understand why change initiatives succeed or fail in long-term care organizations. Four case studies from Québec, Canada were contrasted retrospectively. A constipation and restraints program succeeded, while an incontinence and falls program failed. Successful programs were distinguished by the use of a change strategy that combined "let-it happen," "help-it happen," and "make-it happen" interventions to create senses of urgency, solidarity, intensity, and accumulation. These four active ingredients of the successful change strategies propelled their respective change processes forward to completion. This paper provides concrete examples of successful and unsuccessful combinations of "let-it happen," "help-it happen," and "make-it happen" change management interventions. Change managers (CM) can draw upon these examples to best tailor and energize change management strategies in their own organizations.

Schools' absorptive capacity to innovate in health promotion

PURPOSE

A comprehensive "health promoting schools" (HPS) approach is advocated by the World Health Organization to foster the health of students. To date, few studies have evaluated schools' capacity to implement it in an optimal way. The purpose of this paper is to present a conceptual framework that identifies core features likely to facilitate the incorporation of innovation, such as HPS, into school functioning.

DESIGN/METHODOLOGY/APPROACH

The framework was built by combining dimensions derived from two major strands of literature, i.e. management and HPS. It has taken root in Zahra and George's model of organisation absorptive capacity (AC) for new knowledge but has been adapted to better explore AC in a school context. The contrasting cases of two secondary schools that adopted a HPS approach in Quebec, Canada, for at least three years were used to illustrate the value of the framework.

FINDINGS

The framework proposed is a multidimensional model that considers components such as modulators, antecedents, integration mechanisms and strategic levers as potential determinants of AC, i.e. acquisition, assimilation, transformation and exploitation. The conceptual framework helped to qualify and compare AC regarding HPS in the two cases and holds promise to appreciate mechanisms having the greatest influence on it.

ORIGINALITY/VALUE

The framework can serve as a conceptual guide to facilitate the absorption of innovation in schools and to design future empirical research to better understand the underlying process by which schools strengthen their capacities to become settings conducive to the health of youth.

Interprofessional meetings in geriatric assessment units: a matter of care organization

Inpatient geriatric assessment units (GAUs) exist in Quebec, Canada, to deliver comprehensive, integrated care to older vulnerable patients. Most cases should be discussed at interprofessional meetings (IMs), but research has shown this not to be so for 39% of GAU patients. Consequently, a study was undertaken to (1) describe GAU team composition and (2) identify GAU and patient characteristics associated with case discussion at IMs at least once during a patient's stay. To this end, 877 hospitalization records from 44 GAUs were reviewed. Results showed most teams were composed of attending physicians, nurses, physical and occupational therapists, dietitians and social workers; 66% included clinical pharmacists and 43% liaison nurses. Multilevel modeling showed longer length of stay to be the strongest predictor of case discussion at an IM. Case discussion was also more likely for patients admitted via in- or inter-hospital transfer rather than via the emergency department, if the GAU included a liaison nurse, and if the GAU was not located in an urban area. In summary, case discussion at an IM depended more on how and where a patient was admitted than on the patient characteristics per se, suggesting that this is a matter of care organization.

Professional development in the context of Healthy Schools in Quebec

This article reports preliminary research results on a professional development (PD) model as a mechanism for supporting absorption of the Healthy School (HS) approach into school functioning. The purpose of our study was to document the model implementation process and understand whether it influenced, or not, the accompanied actors' knowledge and practices about HS. The theoretical basis of the model and a description of its implementation, its appreciation by actors and its influence on their knowledge and confidence are presented. The research was conducted in three Quebec schools that had adopted this approach for at least 2 years. Multiple case study methodology, with pre- (T0) and post- (T1) intervention comparison, was adopted. The results disclose that the PD model implemented, which involves socio-constructivist accompaniment, has several assets that support the acquisition and application of new knowledge related to HS in order to promote its absorption within schools. Our findings indicate that PD likely reinforced the actors' knowledge and understanding as well as their confidence. The lessons drawn from the evaluation of this PD model could serve to enhance accompaniment methods implemented to promote the absorption of such initiatives in schools. Our data highlight the relevance and effectiveness of accompaniment anchored in action, calling for practice based on reflection and expert recommendations to meet the objectives of health and academic success.

Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people

INTRODUCTION

The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow-up frail and disabled community-dwelling older people.

THEORY AND METHOD

A RIGOROUS PROCESS WAS APPLIED ACCORDING TO A SERIES OF STEPS: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team.

RESULTS

ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans.

CONCLUSION

Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

Use of standardized multidimensional evaluation tools and the emergence of the case manager's professional identity in France

In France, the national public health plan proposes a group of innovations including the initiation of case management for older adults in complex situations, particularly those with cognitive disorders. In this context, public authorities asked case managers to use a standardized multidimensional evaluation tool. The results of a qualitative study on the pertinence of such a tool relative to the emergence of this new professional field are described. Early use of an evaluation tool seems to be linked to the emergence of a new professional identity for recently recruited case managers. Factors determining the strength of this link are training tool standardization, computerization, and local structure's involvement. Our results contribute to identifying one of the ways by which professional identity can be changed to become a case manager.

Facilitating change among nursing assistants in long term care

In this article, the authors consider the implementation of change in long term care organizations (LTCOs) and present their study describing the process by which new nursing assistants are informally integrated into LTCOs in Quebec, Canada. The study method included 23 in-depth interviews with nursing assistants in two long term care centres. The findings enabled the authors to describe the informal process by which new nursing assistants are integrated into LTCOs and the manner in which informal work strategies enhance the work of nursing care, thus enabling the nursing assistants to manage heavy workloads. The authors discuss whether this teamwork is a deterrent to change or a lever for change and address issues regarding the collective structure of nursing assistant teams. Implications for practice include a Five-Step Innovation Plan. In conclusion, the authors propose that organizational change among nursing assistants in a LTCO is best accomplished when the leaders consider the nursing assistants' strong sense of community to be a change engine rather than a change obstacle.

Analysis of case management programs for patients with dementia: a systematic review

BACKGROUND

People suffering from dementia are particularly vulnerable to the gaps between the health and social service systems. Case management is a professional field that seeks to fill in these gaps and remedy this fragmentation.

METHODS

We report the results of a systematic literature review of the impact of case management programs on clinical outcomes and the utilization of resources by persons with dementia. We focused on randomized controlled trials (RCTs) and attempted to identify the factors that might contribute to greater program efficacy. Because the evaluation methods in these studies varied, we used the effect size method to estimate the magnitude of the statistically significant effects reported.

RESULTS

Our search strategy identified 17 references relating to six RCTs. Four of these six RCTs reported moderately statistically significant effects (effect size, 0.2-0.8) on their primary end point: the clinical outcome in three and resource utilization in one. Two of the RCTs reported weak or no effects (effect size, <0.2) on their primary end point. Because of the wide variety of the end points used, an overall effect size could not be calculated. Parameters that appear to be related to greater case management efficacy are the integration level between the health and social service organizations and the intensity of the case management.

CONCLUSIONS

Integration and case management intensity seem to determine the magnitude of the clinical effects in this new professional field. Further studies are needed to clarify the economic impact.

Le rôle des proches dans le processus de détermination de l’inaptitude de la personne âgée en perte d’autonomie du point de vue des professionnels

La détermination de l’inaptitude est un processus à la fois juridique et clinique encadré par des lois et normes professionnelles qui établissent la nécessité de consulter les proches de la personne dont on évalue l’aptitude. Pourtant, le rôle de ces proches dans le processus n’a pas fait l’objet d’études. Le présent article rend compte des diverses représentations de ce rôle du point de vue des professionnels impliqués dans la détermination de l’inaptitude et du jugement qu’ils posent au sujet de l’adéquation ou de l’inadéquation du proche à assurer la protection de la personne inapte. Les représentations que les professionnels se font des proches dans le processus de détermination de l’inaptitude se distribuent en fonction d’un jugement d’adéquation ou d’inadéquation du proche à assurer la protection de la personne inapte. Ces représentations, qui sont étroitement liées aux rôles que jouent les proches tout au long du processus, forment trois figures types, soit 1) le proche collaborateur, 2) le proche protecteur et 3) le proche problème.

Studying integrated health care systems with a structurationist approach

Introduction

To implement an integrated health care system is not an easy task and to ensure its sustainability is yet more difficult.

Aim

Discuss how a structurationist approach can shed light on the stakes of these processes and guide the managers of such endeavours.

Theory and method

Structuration theory [1] has been used by numerous authors to cast new light on complex organizational phenomena. One of the central tenets of this theory is that social systems, such as integrated health care systems, are recurrent social practices across time-space and are characterized by structural properties which simultaneously constrain and enable the constitutive social actors who reproduce and transform the system through their practices. We will illustrate our theoretical standpoint with empirical material gathered during the study of an integrated health care system for the frail elderly in Quebec, Canada. This system has been implemented in 1997 and is still working well in 2010.

Results and conclusion

To implement an integrated health care system that is both effective and sustainable, its managers must shrewdly allow for the existing system and progressively introduce changes in the way managers and practitioners at work in the system view their role and act on a daily basis.

Collaboration between case managers and family caregivers in a context of integrated care for the frail elderly

Purpose

Case management is a human device which’s purpose is to enhance the quality of services by improving their coordination. However, the case manager is not the sole bearer of the coordination duty; the first line medical doctor, the service user himself and his family caregiver may also contribute. The family caregiver represents a very important coordinator whose contribution to case management remains feebly recognized. This communication focuses on the family caregiver’s contribution to the general coordination of services.

Theory

Even though few studies have focused on family caregivers’ roles in services’ coordination, their role is recognized as crucial. Diverse models of the family caregiver’s role will be utilized to orientate our analysis of their contributions to general coordination.

Methods

Employing an embedded case study design, we conducted 18 paired interviews with user/caregiver dyads (six in three different integrated care networks) following a method aimed at making explicit their concrete coordination practices.

Results and conclusions

Services’ coordination is marked by a delay between the emergence of a clinical need and the implementation of a service, which is partially compensated by the family caregiver. Hence, global coordination is temporally out of phase with the user’s needs.

Analysis of the continuity of services from the viewpoint of clinical files in the perspective of quality improvement

Purpose

Theory

Methods

Results and conclusions

Study of the composition of the various forms of coordination in the case management practice

Purpose

Theory

Methods

Results and conclusions

How divergent conceptions among health and education stakeholders influence the dissemination of healthy schools in Quebec

This paper focuses on dissemination of the healthy schools (HS) approach in the province of Quebec, Canada. Dissemination aims at raising awareness about HS and promoting its adhesion among actors concerned with youth health in school. As HS is a joint initiative based on agreement and collaboration between health and educational sectors, the positions of stakeholders that foster cooperation between these sectors were considered to be critical to optimize its dissemination. The study's objectives were to: (i) examine and contrast the stakeholders' conceptions of HS and (ii) understand how converging and diverging stakeholders' positions on HS favourably or negatively influence its dissemination in Quebec. Gray's analytical approach to collaboration and its focus on stakeholders' mindframe about a domain served as a conceptual lens to examine stakeholders' positions regarding HS. Collection methods included documentary analysis and semi-structured interviews of 34 key internal and external informants at the provincial, regional and local levels. The results showed consensual adhesion to fundamental principles of the HS approach. However, differences in conceptualization between provincial authorities of the two sectors concerning the way to disseminate HS have been observed. These differences represented a significant barrier to HS optimal dissemination. A dialogue between the two authorities appears to be essential to arrive at a negotiated and shared conceptualization of this issue in the Quebec context, thus allowing agreements for adequate support. The results may serve as the basis for a more fruitful dialogue between actors from the two sectors, at different administrative levels.

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.

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.

Attributes of conception of relational continuity: an essential component of the integration of services for frail older people

Purpose

Present the results of an exploratory study which aimed to identify the attributes of relational continuity as conceived by the actors involved in the organization of services to frail older people.

Theory

The lengthening of the duration of life with autonomy loss warrants a transformation of the response to the needs of older people. The organization of services must evolve from a hospital-centered model to a residence-centered model better adapted to long-term care. This refocus on residential care provokes a multiplication of service providers which must be coordinated to ensure continuity of care [1]. Amongst the three forms of continuity (informational, management and relational) [2], relational continuity appears as the least documented and most difficult to measure.

Methods

Twenty-seven interviews with practitioners, managers, family caregivers and users were conducted and analysed using a content analysis approach.

Results and conclusions

While the family caregivers and users stressed the psycho-affective nature of the care relationship, the practitioners viewed it as a means to ensure the adequacy of services. From the user's viewpoint, the relationship is not the responsibility of one professional, but of a collective effort that may carry his voice across the services organization.

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.

Contributions of family caregivers to the coordination of services for the frail elderly

Purpose

This presentation concerns the contribution of family caregivers to the coordination of services for the frail elderly.

Theory

The role of family caregivers is partly conditioned by the conjuncture of health and social care organization. In recent years, many efforts were devoted to the creation of services integration devices which aim to improve user experience in particularly fragmented services organization [1]. In this context, family caregivers increasingly draw from their personal resources to care for their loved ones. In fact, Ducharme and colleagues [2] estimated that 80% of the care received is dispensed by family caregivers. Therefore, a better understanding of the contribution of family caregivers to coordinated care was deemed pertinent.

Methods

Our exploratory study consisted of 12 interviews with family caregivers and frail elderly users concerning their coordination experience.

Results and conclusions

In all circumstances, family caregivers have an important contribution to coordination. In fact, they absorb the coordination surplus required during the pre-installation phase of case management or during the users' episodes of transforming needs. This reveals a temporal gap between the need for coordination and the effective deployment of case management. Therefore, they appear as the primary bearers of services coordination.