Evaluate the implementation of case management by a family medicine group (FMG) nurse and of self-management support groups for high service users in FMGs. This intervention improved integration of care based on patient experience, reduced psychological distress, and improved patients’ and families’ sense of safety. Participants in self-management support groups reported an overall improvement in their self-management skills.
Evaluate the implementation of case management by a nurse-social worker team for high service users in family medicine groups (FMGs) and make recommendations for wider deployment. This project led to relevant recommendations related to the implementation of this model of care.
Demonstration project of the Quebec Learning Health System SUPPORT Unit
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Describe a harmonized model of case management based on the evaluation of case management programs deployed in six facilities of Saguenay-Lac-St-Jean regional health authority. The study highlights the importance of tailoring the trajectory of care and intensity of intervention to the degree of complexity of patients. Case management programs help improve the integration of care and services.
Evaluate how and in what context primary care case management for frequent users improves outcomes for frequent users with chronic conditions. The study presents contexts that promote case manager and patient engagement in case management and produce positive effects when the right mechanisms are activated.
Develop and validate a short, self-administered screening tool to identify chronically ill patients with complex health needs early. The study led to the development of CONECT-6, a tool of six dichotomous questions with “yes” or “no” answer choices.
To implement and evaluate a case management intervention in ten primary care clinics in five Canadian provinces in partnership with patients. Results to come.
Implement and evaluate an integrated case management program for frequent users of health services where nurses from primary care clinics work closely with a hospital case manager. The leadership of the health professionals involved and the support of the physician in charge of the clinic are necessary for a good implementation of the program, which leads to good results afterwards.
To implement and evaluate a telehealth case management intervention in primary care for patients with complex needs in three Canadian provinces. Results to come.
Describe FMGs and their regional health authority or community network partners who have developed innovative partnerships and better understand the winning conditions to be put in place to foster such partnerships. Results to come.
To better understand the partnerships between family medicine groups and community partners. Results to come.
Pilot project for the implementation of the V1SAGES approach. Results to come.
To better understand the care transition experience of patients with complex needs and their families in community, primary care and hospital settings. Results to come.