V1SAGES 2: Partners for an Optimal Organization of the Continuum of Care for Frequent Users of Health and Social Services


  • Canadian Institutes of Health Research (CIHR)
  • Fonds de recherche du Québec en santé (FRQS)
  • Saguenay-Lac-Saint-Jean regional health authority (CIUSSS)
  • Fondation de Ma Vie
  • MediaMed Technologies

The purpose of this project was to describe a harmonized model of case management based on the evaluation of case management programs deployed in six facilities of Saguenay-Lac-Saint-Jean regional health authority (CIUSSS) in order to improve these programs while creating new case management  knowledge that could be useful in other contexts.

Case management programs help improve the integration of care and services. The skills, leadership and experience of the case manager, providers’ access to the individualized service plan (ISP), the consideration of patient and family members’ needs and their participation in decision-making, and the provision of self-management support have an impact on integrated care and health service utilization.

The study highlights the importance of tailoring the trajectory and the intensity of intervention to the degree of complexity of the patients. A harmonized model of case management (logic model) was developed by the research team in close collaboration with decision makers, so that they can better understand the causal links between the context where the case management program was implemented, the resources dedicated to it, the performed activities, and the expected outcomes for both patients and the healthcare system. Thus, informed adaptations can be made in a continuous improvement perspective.

Click here to see the project team 

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