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

2014-2018

- Canadian Institutes of Health Research (CIHR)
- Fonds de recherche du Québec en santé (FRQS)
- Saguenay-Lac-St-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-St-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. Collaboration allows decision-makers to gain a better understanding of the causal links between the context of the case management program, the resources dedicated to it, the activities of the actors involved, and the expected outcomes for both patients and the healthcare system. Thus, informed changes can be made, supporting continuous improvement.
Click here to see the project team
Articles, presentations and posters
Protocol
Results
- Case management programs for improving integrated care for frequent users of healthcare services: an implementation analysis.
- Evaluating complex interventions in real context: Logic analysis of a case management program for frequent users of healthcare services
Scientific presentations
- Case management for frequent users of healthcare services: a logic model presenting links between resources, activities and outcomes. Conférence de la Canadian Association for Health Services and Policy Research (CAHSPR) 2019.
- Implementation analysis of case management programs for frequent users of healthcare services: a multiple embedded case study. Conférence annuelle du North American Primary Care Research Group (NAPCRG) 2020.
Scientific posters
- Case management program for frequent users of healthcare services: an implementation analysis. Conférence annuelle du North American Primary Care Research Group (NAPCRG) 2019.
- Evaluating complex interventions: Logic analysis of a case management program for frequent users of healthcare services. Conférence annuelle du North American Primary Care Research Group (NAPCRG) 2019.