The home as a site for long-term care: meanings and management of bodies and spaces

This paper is concerned with the constitution of the home as a landscape of care in a climate of extensive cost-cutting measures to community provided health care. It draws on data from a multi-disciplinary investigation of various dimensions of the home as a site of long-term care; this paper is concerned specifically with long-term health and associated home-care services provided by paid workers. Through analysis of interviews with adult care recipients and field observations, it examines the micro-scale processes through which the home is reconstructed as caregiving space, highlighting the negotiation of meanings of bodies and homes as fields of knowledge. It argues that the possibilities for the effective negotiation of body knowledge and homespace boundaries that are integral to the production of 'caring' space are embedded in and constrained by policies and practices constructed at a scale beyond home.

Quebec mental health services networks: models and implementation

PURPOSE

In the transformation of health care systems, the introduction of integrated service networks is considered to be one of the main solutions for enhancing efficiency. In the last few years, a wealth of literature has emerged on the topic of services integration. However, the question of how integrated service networks should be modelled to suit different implementation contexts has barely been touched. To fill that gap, this article presents four models for the organization of mental health integrated networks.

DATA SOURCES

The proposed models are drawn from three recently published studies on mental health integrated services in the province of Quebec (Canada) with the author as principal investigator.

DESCRIPTION

Following an explanation of the concept of integrated service network and a description of the Quebec context for mental health networks, the models, applicable in all settings: rural, urban or semi-urban, and metropolitan, and summarized in four figures, are presented.

DISCUSSION AND CONCLUSION

To apply the models successfully, the necessity of rallying all the actors of a system, from the strategic, tactical and operational levels, according to the type of integration involved: functional/administrative, clinical and physician-system is highlighted. The importance of formalizing activities among organizations and actors in a network and reinforcing the governing mechanisms at the local level is also underlined. Finally, a number of integration strategies and key conditions of success to operationalize integrated service networks are suggested.

A generative response to palliative service capacity in Canada

PURPOSE

This paper situates a large-scale learning and service development capacity-building initiative for hospice palliative care services within the current Canadian policy context for use by international readers.

DESIGN/METHODOLOGY/APPROACH

In 2000 a national initiative using action research as its design was crafted to support continuing professional development and knowledge management in primary-health care environments.

FINDINGS

The Canadian health policy context is complex and requires innovative solutions to achieve desired changes in response to emerging population health demands for quality end-of-life care. Employment of educational and social science constructs, including complexity theory, communities of practice, transformative learning theory, and workplace learning methods, has proven helpful in supporting the creation of national capacity for hospice palliative care.

RESEARCH LIMITATIONS/IMPLICATIONS

There is a significant contribution for social scientists to make in aiding a better understanding of the complexity in health systems. At the same time, an aging population in industrial countries demands more active engagement of legal and bioethical scholars in a range of emerging policy and legislative questions about quality end-of-life care. Educational research is also required to understand better and reform curricula to prepare an emerging generation of health science practitioners for the demands of an aging population.

PRACTICAL IMPLICATIONS

Changing health service delivery environments demand rethinking of the knowledge and skills leaders require to influence desired change. A broader understanding of where and how learning takes place is essential for enhancing the quality of patient care.

ORIGINALITY/VALUE

The Pallium Project represents a generative response to facilitating learning and building longer-term system capacity. The journey of project development to date illustrates some important lessons that can be adopted from hospice palliative care to inform other primary-health care initiatives, including, potentially, mental health, cardiology, diabetes, geriatrics, where productive change can result from productively linking specialists and primary-care colleagues.

Developing global leaders through doctoral education

Nursing leadership has become a major theme of discussions in many countries. The phenomenon is also present in nursing as the profession is redesigning and reinventing itself in all domains of practice. This paper discusses the development of global nursing leaders through doctoral education in the context of 21st century realities. Next, two meanings of global leadership of nursing are reviewed. Finally, doctoral education is focused by looking at worldviews and the challenges ahead in preparing global nursing leaders for the 21st century.

Physicians' perceptions of integration in three Western Canada Health Regions

Over the post decade, provincial governments have embarked on ambitious plans to better integrate their healthcare systems, through the introduction of regional governance and management structures. The objective of this study was to examine physicians' perceptions of the current level and facilitators/barriers to integration in three Western Canada Health Regions. Three approaches to integration were investigated: functional, clinical services, and physician system integration. Physicians perceived that functional integration within each region was questionable. Clinical services were the least integrated approach. Physician system integration was rated highest of the approaches, particularly adherence to clinical practice guidelines usage. Physicians' perspectives of integrated health delivery systems do not appear to be influenced by regional size, maturity, urbanicity or facilities. Facilitators of integration were communication among health professionals and service providers, and using a multi-disciplinary team approach in delivery of healthcare in both regions. Barriers to integration were organizational culture, access to specialists and clinical services, and health information records. On a scale of 1-5, all three regions are at the beginning of an integrated health delivery system. Three global suggestions were provided to further integration of health delivery services: physicians should be involved in decision-making process at the Board level, clinical services should be patient-centred, and physicians endorsed the use of multi-disciplinary teams.

Patients' perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies

BACKGROUND

The delivery of technology-enhanced home care is growing in most industrialized countries. The objective of our study was to document, from the patient's perspective, how the level of user-friendliness of medical technology influences its integration into the private and social lives of patients. Understanding what makes a technology user-friendly should help improve the design of home care services.

METHODS

Four home care interventions that are frequently used and vary in their technical and clinical features were selected: Antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. Our qualitative study relied on the triangulation of three sources of data: 1) interviews with patients (n = 16); 2) interviews with carers (n = 6); and 3) direct observation of nursing visits of a different set of patients (n = 16). Participants of varying socioeconomic status were recruited through primary care organizations and hospitals that deliver home care within 100 km of Montreal, the largest urban area in the province of Quebec, Canada.

RESULTS

The four interventions have both a negative and positive effect on patients' lives. These technologies were rarely perceived as user-friendly, and user-acceptance was closely linked to user-competence. Compared with acute I.V. patients, who tended to be passive, chronic patients seemed keener to master technical aspects. While some of the technical and human barriers were managed well in the home setting, engaging in the social world was more problematic. Most patients found it difficult to maintain a regular job because of the high frequency of treatment, while some carers found their autonomy and social lives restricted. Patients also tended to withdraw from social activities because of social stigmatization and technical barriers.

CONCLUSIONS

While technology contributes to improving the patients' health, it also imposes significant constraints on their lives. Policies aimed at developing home care must clearly integrate principles and resources supporting the appropriate use of technology. Close monitoring of patients should be part of all technology-enhanced home care programs.

Factors that impact the transfer and retention of best practices for reducing error in hospitals

Recent research and theory in organizational learning literature advances seven propositions that illuminate the nature and complexities of transferring and retaining best practices for reducing error and increasing patient safety in U.S. and Canadian hospitals.

Complementary medicine and older people: past research and future directions

Due to the natural aging processes, older people are particularly susceptible to a range of chronic health conditions. However, despite that research has indicated that chronic health conditions and disability act as reliable predictors of complementary/alternative medicine (CAM) use, despite research evidence that older people are significant consumers of CAM, and regardless of the potential for CAM to enhance successful aging, reduce frailty, and increase independence and quality of life in older persons, older people's use of CAM therapies remains under-researched. This paper reviews what existing research literature is there on CAM use in older age; considers rates of and potential for use, features of and barriers to use, and economic, effectiveness and safety issues. From these beginnings, outlined is a wide-ranging research agenda on CAM and older people.

From parallel practice to integrative health care: a conceptual framework

Background

"Integrative health care" has become a common term to describe teams of health care providers working together to provide patient care. However this term has not been well-defined and likely means many different things to different people. The purpose of this paper is to develop a conceptual framework for describing, comparing and evaluating different forms of team-oriented health care practices that have evolved in Western health care systems.

Discussion

Seven different models of team-oriented health care practice are illustrated in this paper: parallel, consultative, collaborative, coordinated, multidisciplinary, interdisciplinary and integrative. Each of these models occupies a position along the proposed continuum from the non-integrative to fully integrative approach they take to patient care. The framework is developed around four key components of integrative health care practice: philosophy/values; structure, process and outcomes.

Summary

This framework can be used by patients and health care practitioners to determine what styles of practice meet their needs and by policy makers, healthcare managers and researchers to document the evolution of team practices over time. This framework may also facilitate exploration of the relationship between different practice models and health outcomes.

Home care before and after hospitalization for acute myocardial infarction in Alberta, Canada

Home care services are provided to about 10% of those admitted to hospital for acute myocardial infarction and about 20% of those discharged from hospital. The use of home care in patients with an acute myocardial infarction is growing in Alberta over the brief time span of this four year study. Those that received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care.

BACKGROUND

The use of home care before and after hospitalization for acute myocardial infarction is described.

METHODS

Hospital discharge abstracts were used to identify patients hospitalized in alberta, canada for acute myocardial infarction which were then linked to home care administrative data.

RESULTS

There were 12,648 patients with acute myocardial infarction from April 1, 1995 until March 31, 1999. Home care within 60 days prior to hospitalization was provided for 8.7% of patients with acute myocardial infarctions (n = 1097) which significantly (p = 0.023) increased from 7.6% in the fiscal year 1995/6 to 9.5% in the fiscal year 1998/9. Home care within 60 days after hospitalization was provided to 16.4% of patients with acute myocardial infarctions (n = 2076) which significantly (p < 0.000) increased from 14.1% in the fiscal year 1995/6 to 18.1% in fiscal year 1998/9. Recipients of home care were significantly older, had more comorbidities, and greater severity of illness, but were less likely to undergo coronary artery revascularization during hospitalization. After multivariate adjustment, length of hospital stay, 60 day re-admissions, and mortality were higher in those receiving home care post hospitalization. Nearly half of those receiving home care prior to hospitalization died within one year. 80% of those receiving home care prior to admission also received home care services after hospitalization.

CONCLUSION

Those patients who received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care.

Conceptualizing and validating the human services integration measure

Purposes

This paper proposes both a model and a measure of human service integration through strategic alliances with autonomous services as one way to achieve comprehensive health and social services for target populations.

Theory

Diverse theories of integrated service delivery and collaboration were combined reflecting integration along a continuum of care within a service sector, across service sectors and between public, not-for-profit and private sectors of financing services.

Methods

A measure of human service integration is proposed and tested. The measure identifies the scope and depth of integration for each sector and service that make up a total service network. It captures in quantitative terms both intra and inter sectoral service integration.

Results

Results are provided using the Human Service Measure in two networks of services involved in promoting Healthy Babies and Healthy Children known to have more and less integration.

Conclusions

The instrument demonstrated discriminate validity with scores correctly distinguishing the two networks. The instrument does not correlate (r=0.13) with Weiss (2001) measure of partnership synergy confirming that it measures a distinct component of integration.

Discussion

We recommend the combined use of the proposed measure and the Weiss (2001) measure to more completely capture the scope and depth of integration efforts as well as the nature of the functioning of a service program or network.

Alternative funding for academic medicine: experience at a Canadian Health Sciences Center

In 1994 the School of Medicine of Queen's University in Kingston, Ontario, its clinical teachers, and the three principal teaching hospitals initiated a new approach to funding, the Alternative Funding Plan, a pragmatic response to the inability of fee-for-service billing by clinical faculty to subsidize the academic mission of the health sciences center. The center was funded to provide a package of service and academic deliverables (outputs), rather than on the basis of payment for physician clinical activity (inputs). The new plan required a new governance structure representing stakeholders and raised a number of important issues: how to reconcile the preservation of physician professional autonomy with corporate responsibilities; how to gather requisite information so as to equitably allocate resources; and how to report to the Ontario Ministry of Health and Long-term Care in order to demonstrate accountability. In subsequent iterations of the agreement it was necessary to address issues of flexibility resulting from locked-in funding levels and to devise meaningful performance measures for departments and the center as a whole. The authors conclude that the Alternative Funding Plan represents a successful innovation in funding for an academic health sciences center in that it has created financial stability, as well as modest positive effects for education and research. The Ontario government hopes to replicate the model at the province's other four health sciences centers, and it may have applicability in any jurisdiction in which the costs of medical education outstrip the capacity of faculty clinical earnings.

Implementing evidence-based nursing practice: a tale of two intrapartum nursing units

Despite concerns that the rise of evidence-based practice threatens to transform nursing practice into a performative exercise disciplined by scientific knowledge, others have found that scientific knowledge is by no means the preeminent source of knowledge within the dynamic settings of health-care. We argue that the contexts within which evidence-based innovations are implemented are as influential in the outcomes as the individual practitioners who attempt these changes. A focused ethnography was done in follow-up to an earlier trial that evaluated the effectiveness of a marketing strategy to encourage the adoption of evidence-based intrapartum nursing practice. Bourdieu's (1990, 1991) concepts of habitus, capital and social field were used in our refinement of the analysis of the ethnographic findings. Nursing leadership, interprofessional struggle with physicians, the characteristics of the community and the physical environment were prominent issues at all of the sites. Detailed descriptions of the sociohistorical context and of the experiences at two sites are presented to illustrate the complexities encountered when implementing innovations.

Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um "sistema sem muros"

Neste texto, partimos do pressuposto de que a integralidade da atenção é um eixo prioritário da investigação e avaliação dos serviços e sistemas de saúde, estruturados como redes assistenciais interorganizacionais que articulam dimensões clínicas, funcionais, normativas e sistêmicas em sua operacionalização, reconhecendo que nenhuma organização reúne a totalidade dos recursos e competências necessárias para a solução dos problemas de saúde de uma população, em seus diversos ciclos de vida. Em virtude da complexidade desse "sistema sem muros", que elimina as barreiras de acesso entre os diversos níveis de atenção, em resposta às necessidades de saúde nos âmbitos local e regional, julgamos oportuno compartilhar algumas "lições preliminares" aprendidas em experiências pessoais e na literatura sobre a integração de serviços, que nos parecem de interesse comum aos pesquisadores e gestores comprometidos com a sua implantação.

What is important to continuity in home care?

In Canada, home care is growing rapidly. Each province takes a somewhat different approach to its delivery. Ontario uses a competitive bidding model to award contracts to community agencies that bid for service delivery rights. Contracts are to be awarded based on quality and price. However, the attributes thought to contribute to high quality, such as continuity of care, are not clearly defined and are not measured. We sought to identify factors that were important to experiencing continuity of care in home care. We interviewed home care clients and their caregivers, workers in the home care system (nursing and homemaking service providers, case managers) and physicians whose patients use home care. During in-depth interviews with these key stakeholders, they described the conditions that led to continuity of care in home care. Service providers and case managers were also asked about the types of clients who need a high level of care continuity. Care that is experienced as running smoothly, that responds to clients' needs and requires no special effort for clients to maintain, was seen as having continuity. The attributes of care experienced as facilitating continuity could be grouped under two dimensions of care-managing care (care planning, monitoring and review; and care coordination) and direct service provision (uninterrupted service delivery; consistent, appropriate knowledge and skills; ongoing accurate observation; trusting relationship between service provider and client/caregiver; rapport among team members; and consistent timing). Different stakeholders emphasized different attributes of care as most important to continuity. Clients included consistency of timing of service delivery while rarely mentioning care management issues. They emphasized the importance of consistent knowledge and skills in the workers and trusting relationships as important to experiencing care continuity. The description of attributes of continuity of home care that emerged from this study is compared to definitions found in the nursing, mental health and primary care literature.

Les soins de longue durée aux personnes âgées: Choix d'un système clinico-administratif dans le contexte d'un réseau de soins intégrés

For the past 10 years, in long-term care systems, we have witnessed the accelerated deployment of casemix management systems. A casemix is formed by clusters, defined by individual characteristics that explain similar resource use. However, certain questions regarding the development of these systems must be raised. Moreover, none of these systems was developed in the context of an integrated care organization that can track the progress of a dependent elderly person through every kind of care arrangement available—from own home, through intermediate facility, to long-term care institution. This article emphasizes the necessity of being well informed about the features of existing systems, in order to choose or develop the system that best answers the goals of a particular health care system. Finally, it underlines important elements that should be considered in each step of the development of a casemix system in this context.

Social group work: building a professional collective of hospital social workers

Deconstruction of traditional social work departments can isolate social workers from their primary source of professional affiliation, leaving them without the support to take stands on controversial patient care issues. This paper describes an alternative: the building of a powerful social work collective based on social group work theory that potentiates professional practice while transcending management forms. The model includes group supervision, but moves beyond it to utilize the social work group as a central organizing principle. At the heart of the collective are the elements of professional accountability, support, autonomy, and collaborative decision- making within democratic peer group structures. The authors highlight current management theory, distinctions that create an authentic social work value-based practice, and outcomes for social workers, their clients, and colleagues.

The structure of everyday self-care decision making in chronic illness

As health care reform strategists increasingly recognize the critically important potential of effective everyday self-care decision making for reducing the burden of illness and the strain on health service systems, we must find ways to understand and support it. In this study, the authors investigate persons with expertise in self-care management of type 2 diabetes, HIV/AIDS, and multiple sclerosis to understand how everyday self-care decision making is learned and experienced. They used interview, think-aloud, and focus groups to construct an account of how persons affected by these chronic diseases make decisions in relation to the choices in their everyday lives and learn to manage the untoward effects of these conditions according to their unique contexts and values. The findings form a conceptual foundation for ongoing inquiry into this complex phenomenon and provide insights that might assist clinicians to understand more fully the responses and attitudes of those they serve.

Devolving healthcare delivery to regional health authorities: is health technology assessment prepared to follow?

Since the establishment of health technology assessment units in the latter 1980s, Canada has witnessed an unprecedented transformation of the governance, management and service delivery of its healthcare system. In Alberta, this transformation culminated in the establishment of regional health authorities that provide integrated healthcare to Albertans. With the shift of responsibility for healthcare delivery from the provincial to the regional level, the Alberta Heritage Foundation for Medical Research HTA unit recognized that for health technology assessment to continue to be relevant, it must follow this change. Four steps were taken to refocus the unit's scope: a thorough analysis of the healthcare environment; face-to-face interviews with the chief executive officers of the regions; the development of a framework for HTA in the regions; and the organization of a conference on evidence-based decision making. These steps were helpful in bringing HTA to the attention of regional decision makers. A formal, analytical assessment of the regional healthcare environment, provision of general information (through the framework and conference) and individual information (through face-to-face interviews) enabled a proactive engagement with regions. However, to meet the demands and needs of a population that expects comprehensive coverage that delivers "state of the art" diagnostics and treatments, the efficacy and effectiveness of interventions can sometimes be of subordinate importance.

Access to intensive care unit beds for neurosurgery patients: a qualitative case study

OBJECTIVES

The purpose of this study was to describe the process used to decide which patients are admitted to the intensive care unit (ICU) at a hospital with special focus on access for neurosurgery patients, and evaluate it using "accountability for reasonableness".

METHODS

Qualitative case study methodology was used. Data were collected from documents, interviews with key informants, and observations. The data were subjected to thematic analysis and evaluated using the four conditions of "accountability for reasonableness" (relevance, publicity, appeals, enforcement) to identify good practices and opportunities for improvement.

RESULTS

ICU admissions were based on the referring physician's assessment of the medical need of the patient for an ICU bed. Non-medical criteria (for example, family wishes) also influenced admission decisions. Although there was an ICU bed allocation policy, patient need always superceded the bed allocation policy. ICU admission guidelines were not used. Admission decisions and reasons were disseminated to the ICU charge nurse, the bed coordinator, the ICU resident, the intensivist, and the requesting physician/surgeon by word of mouth and by written documentation in the patient's chart, but not to the patient or family. Appeals occurred informally, through negotiations between clinicians. Enforcement of relevance, publicity, and appeals was felt to be either non-existent or deficient.

CONCLUSIONS

Conducting a case study of priority setting decisions for patients requiring ICU beds, with a special focus on neurosurgical patients, and applying the ethical framework "accountability for reasonableness" can help critical care units improve the fairness of their priority setting.

Patient safety in surgery: error detection and prevention

Error in medicine is becoming a well recognized phenomenon. The U.S. Institute of Medicine's publication in 1999 included estimations that medical error is the eighth leading cause of death in the United States and results in up to 100,000 deaths annually. Retrospective studies and a few prospective studies are shedding more light on this challenging problem. Strategies to reduce error and increase patient safety have not been widely developed or embraced by surgeons for a variety of reasons. We provide a review on patient safety aimed at surgeons that includes definitions, incidence of errors including those in the surgical literature, causes of error, methods of error detection, and strategies to minimize errors and maximize patient safety.

Mis-takes: mistakes in the nurse-person process

This column supports the global mantra to develop mechanisms that address the worldwide crisis in patient safety and demonstrates, using nursing as an example, that the mechanisms currently being developed are too limited. Patient safety initiatives must be expanded to acknowledge and make ways to minimize mis-takes, that is, misconceptions of meaning that emerge when healthcare professionals dismiss, misconstrue, guess, or undervalue patients' perspectives. Commitment to the human becoming school of thought as a guide for practice is suggested as one way to address mis-takes in the nurse-person process.

The influence of cost-effectiveness information on physicians' cancer screening recommendations

Physicians are increasingly faced with choices in which one screening strategy is both more effective and more expensive than another. One way to make such choices is to examine the cost-effectiveness of the more costly strategy over the less costly one. However, little is known about how cost-effectiveness information influences physicians' screening decisions. We surveyed 900 primary care US physicians, and presented each with a hypothetical cancer-screening scenario. We created three familiar screening scenarios, involving cervical, colon, and breast cancer. We also created three unfamiliar screening scenarios. Physicians were randomized to receive one of nine questionnaires, each containing one screening scenario. Three questionnaires posed one of the familiar screening scenarios without cost-effectiveness information, three posed one of the familiar scenarios with cost-effectiveness information, and three posed one of the unfamiliar scenarios with cost-effectiveness information. The cost-effectiveness information for familiar scenarios was drawn from the medical literature. The cost-effectiveness information for unfamiliar scenarios was fabricated to match that of a corresponding familiar scenario. In all questionnaires, physicians were asked what screening alternative they would recommend. A total of 560 physicians responded (65%). For familiar scenarios, providing cost-effectiveness information had at most a small influence on physicians' screening recommendations; it reduced the proportion of physicians recommending annual Pap smears (p=0.003), but did not significantly alter the aggressiveness of colon cancer and breast cancer screening (both p's<0.1). For all three unfamiliar scenarios, physicians were significantly less likely to recommend expensive screening strategies than in corresponding familiar scenarios (all p's<0.001). Physicians' written explanations revealed a number of factors that moderated the influence of cost-effectiveness information on their screening recommendations. Providing physicians with cost-effectiveness information had only a moderate influence on their screening recommendations for cervical, colon, and breast cancer. Significantly, fewer physicians recommended aggressive screening for unfamiliar cancers than for familiar ones, despite similar cost-effectiveness. Physicians are relatively reluctant to abandon common screening strategies, even when they learn that they are expensive, and are hesitant to adopt unfamiliar screening strategies, even when they learn that they are inexpensive.

Health care reform: lessons from Canada

Although Canadian health care seems to be perennially in crisis, access, quality, and satisfaction in Canada are relatively high, and spending is relatively well controlled. The Canadian model is built on a recognition of the limits of markets in distributing medically necessary care. Current issues in financing and delivering health care in Canada deserve attention. Key dilemmas include intergovernmental disputes between the federal and provincial levels of government and determining how to organize care, what to pay for (comprehensiveness), and what incentive structures to put in place for payment. Lessons for the United States include the importance of universal coverage, the advantages of a single payer, and the fact that systems can be organized on a subnational basis.

The use of 'arms-length' organizations for health system change in Ontario, Canada: some observations by insiders

During the past decade, there has been substantial health system reform in the United States, United Kingdom, New Zealand, and many other countries. For the most part, Canada has not pursued 'big bang' health system change but rather a variety of strategies to achieve incremental change. In this paper, we present the ways in which three arms-length organizations have been used by government to effect incremental system change in Ontario during the past several years. We observe that, (1) the influence of politics and political interference can be reduced through an arms-length organization; (2) an arms-length organization with the power to make decisions entails more political risk for government and encounters more scrutiny and criticism by providers and the media than an organization with the power to recommend only; (3) an arms-length organization with a limited lifespan faces more delaying tactics by adversely affected parties than an organization without a limited lifespan; (4) an arms-length organization with perceived influence may attract causes that are not related to its mandate; (5) the importance and difficulty of communicating complex information about system change to a wide variety of audiences cannot be overstated; (6) system change informed by the use of expert opinion encounters less provider resistance and may result in better decisions; and (7) the reputation of the Chair and the perceived competence and experience of the CEO are critical success factors in the success of an arms-length organization.

Running to stand still: change and management in Canadian healthcare

There is a pervasive belief among health system reformers that new public management techniques such as decentralization and market-based approaches will provide the answers to what ails healthcare systems. In this first installment of a two-part discussion, the assumptions and empirical evidence underpinning these techniques are scrutinized, and the effect of their implementation on those who manage the healthcare system is assessed. Other paradigms for delivering healthcare will be considered and described in the second article of this series. Healthcare systems around the world have been buffeted by rising costs, perceived inefficient use of resources, and consumer and provider dissatisfaction with the delivery and outcomes of care.

Home care or long-term care facility: factors that influence the decision

In order to answer the research question--What factors determine if a long-term care client will be cared for at home or in a long-term care facility?--data were collected in five provinces in Canada in urban and rural sites, through focus groups with community care coordinators. A questionnaire provided information about the 89 participants and their workload. Factors are grouped under organizational, system, client, informal provider, formal provider, and case manager factors. Discussion focuses on changes needed to foster more long-term care in the home.

Regional planning implementation and its impact on integration of a mental health care network

This article questions the effectiveness of a managerial tool in changing a health-care system. The process of implementing regional planning and its impact on creating integrated service networks is examined, using a case study and a multi-dimensional analytic model. This model highlights the influence of contextual, structural, cultural and dynamic factors on forming networks. The regional planning developed in the province of Québec (Canada), aimed at a major transformation of the mental health-care system. In each district, organizations working with people who have serious mental disorders were mobilized to plan and implement a more coordinated, continuous and diversified supply of services, under the direction of a regional health body. This study outlines the limitations of regional planning as a tactic for transforming the system. It recommends instead developing more diversified integration strategies to further the process of forming integrated service networks within a complex system. In conclusion, a brief discussion deals with the difficulties related to the study of systemic change implementation.

Using financial incentives to promote shared mental health care

OBJECTIVES

To consider the most common primary care reimbursement structures, to identify incentives inherent in each, and to discuss how each could be used to encourage a shared-care approach to treating mental disorders at the primary care level.

METHOD

Three major financial reimbursement models--fee-for-service, capitation, and blended payment mechanisms--are examined. Each is considered in terms of its risk-sharing elements and the consequent incentives. We offer several scenarios to illustrate how the shared-care practice model might be encouraged under each financing mechanism.

RESULTS

The current fee-for-service system does not encourage shared care. For wide adoption of the shared-care practice model, there must be a change in the reimbursement system's incentives. While none of the financing mechanisms offers a perfect solution, each has potential. Each, however, must be carefully tailored to its environment.

CONCLUSIONS

Financial considerations are just one aspect to achieving shared care. Nevertheless, in designing a system to encourage collaborative, coordinated care for those suffering from mental illness, decision makers should be wary of creating or maintaining obstacles (financial or otherwise) to provision of accessible, high-quality care.