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1.  Divergent modes of integration: the Canadian way 
International Journal of Integrated Care  2011;11(Special 10th Anniversary Edition):e018.
Introduction
The paper highlights key trajectories and outcomes of the recent policy developments toward integrated health care delivery systems in Quebec and Ontario in the primary care sector and in the development of regional networks of health and social services. It particularly explores how policy legacies, interests and cultures may be mitigated to develop and sustain different models of integrated health care that are pertinent to the local contexts.
Policy developments
In Quebec, three decades of iterative developments in health and social services evolved in 2005 into integrated centres for health and social services at the local levels (CSSSs). Four integrated university-based health care networks provide ultra-specialised services. Family Medicine Groups and network clinics are designed to enhance access and continuity of care. Ontario’s Family Health Teams (2004) constitute an innovative public funding for private delivery model that is set up to enhance the capacity of primary care and to facilitate patient-based care. Ontario’s Local Health Integration Networks (LHINs) with autonomous boards of provider organisations are intended to coordinate and integrate care.
Conclusion
Integration strategies in Quebec and Ontario yield clinical autonomy and power to physicians while simultaneously making them key partners in change. Contextual factors combined with increased and varied forms of physician remunerations and incentives mitigated some of the challenges from policy legacies, interests and cultures. Virtual partnerships and accountability agreements between providers promise positive but gradual movement toward integrated health service systems.
PMCID: PMC3180698  PMID: 21954371
Integrated care; integrated health care delivery; primary care; regionalised health services; integrated care models
2.  Mergers and integrated care: the Quebec experience 
As a researcher, I have studied the efforts to increase the integration of health and social services in Quebec, as well as the mergers in the Quebec healthcare system. These mergers have often been presented as a necessary transition to break down the silos that compartmentalize the services dispensed by various organisations. A review of the studies about mergers and integrated care projects in the Quebec healthcare system, since its inception, show that mergers cannot facilitate integrated care unless they are desired and represent for all of the actors involved an appropriate way to deal with service organisation problems. Otherwise, mergers impede integrated care by creating increased bureaucratisation and standardisation and by triggering conflicts and mistrust among the staff of the merged organisations. It is then preferable to let local actors select the most appropriate organisational integration model for their specific context and offer them resources and incentives to cooperate.
PMCID: PMC3653283  PMID: 23687474
integration; merger; health and social services; integrated care; Canada
3.  Primary Care Reform: Can Quebec's Family Medicine Group Model Benefit from the Experience of Ontario's Family Health Teams? 
Healthcare Policy  2011;7(2):e122-e135.
Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care.
PMCID: PMC3287954  PMID: 23115575
4.  Forty years of integration of health and social services in the province of Québec (Canada) 
Québec is the only province in Canada to have integrated health and social services since 1971. A single ministry is responsible for health and social services and this integration is also effective at regional and local agencies. The Local Community Services Centres (Centre locaux de services communautaires—CLSC) were created to provide preventive and primary care and services for a borough in large cities, a medium-size town or many villages in a rural area. In 2003, a major reform created the Health and Social Service Centres (Centre de santé et de services sociaux—CSSS) by merging hospitals, nursing homes and CLSC in 95 areas over the province.
This structural integration has taken place at the same time that the PRISMA model of coordination-type integration for frail older people was being implemented. Integration improves efficiency of the system, but underfunding of long-term care still hampers the provision of adequate home care services. It is now time for moving the beveridge-type funding system to a long-term care public insurance covering the needs of community-dwelling older people with disabilities.
PMCID: PMC3617756
PRISMA; integrated health and social services; Canada; public insurance; long-term care; structural integration
5.  Effect of recent health and social service policy reforms on Britain's mental health system. 
BMJ : British Medical Journal  1995;311(7019):1556-1558.
The introduction of new policies in health and social services in Britain has changed the way community care is provided to seriously mentally ill people. Britain is creating the same problems that have existed in the United States, whereby clinicians struggle to provide services in an environment with multiple payers and perverse incentives. A simple system in Britain has been replaced with complicated organisational and financial structures that require almost impossible feats by local health and social service staff to coordinate care for patients for whom continuity of care is critical for their survival in the community and their wellbeing. Seriously mentally ill people are in the middle of these complicated problems. The creation of a local mental health authority that could be held responsible for community care, as exists in some American states, may be one solution.
PMCID: PMC2548193  PMID: 8520403
6.  Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia 
Background
This study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada.
Methods
A total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND®/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7–9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic.
Results
Initially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57).
Conclusion
A multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate.
doi:10.1186/1472-6963-7-195
PMCID: PMC2225401  PMID: 18047668
7.  Quebec mental health services networks: models and implementation 
Abstract
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.
PMCID: PMC1395508  PMID: 16773157
integrated service networks; integration strategies; mental health network models; Quebec (Canada) mental health system
8.  Networks and social capital: a relational approach to primary healthcare reform 
Collaboration among health care providers and across systems is proposed as a strategy to improve health care delivery the world over. Over the past two decades, health care providers have been encouraged to work in partnership and build interdisciplinary teams. More recently, the notion of networks has entered this discourse but the lack of consensus and understanding about what is meant by adopting a network approach in health services limits its use. Also crucial to this discussion is the work of distinguishing the nature and extent of the impact of social relationships – generally referred to as social capital. In this paper, we review the rationale for collaboration in health care systems; provide an overview and synthesis of key concepts; dispel some common misconceptions of networks; and apply the theory to an example of primary healthcare network reform in Alberta (Canada). Our central thesis is that a relational approach to systems change, one based on a synthesis of network theory and social capital can provide the fodation for a multi-focal approach to primary healthcare reform. Action strategies are recommended to move from an awareness of 'networks' to fully translating knowledge from existing theory to guide planning and practice innovations. Decision-makers are encouraged to consider a multi-focal approach that effectively incorporates a network and social capital approach in planning and evaluating primary healthcare reform.
doi:10.1186/1478-4505-5-9
PMCID: PMC2048492  PMID: 17894868
9.  Prevention in Poland: health care system reform. 
Public Health Reports  1995;110(3):289-294.
Despite the political and economic reforms that have swept Eastern Europe in the past 5 years, there has been little change in Poland's health care system. The Ministry of Health and Social Welfare has targeted preventive care as a priority, yet the enactment of legislation to meet this goal has been slow. The process of reform has been hindered by political stagnation, economic crisis, and a lack of delineation of responsibility for implementing the reforms. Despite the delays in reform, recent developments indicate that a realistic, sustainable restructuring of the health care system is possible, with a focus on preventive services. Recent proposals for change have centered on applying national goals to limited geographic areas, with both local and international support. Regional pilot projects to restructure health care delivery at a community level, local health education and disease prevention initiatives, and a national training program for primary care and family physicians and nurses are being planned. Through regionalization, an increase in responsibility for both the physician and the patient, and redefinition of primary health care and the role of family physicians, isolated local movements and pilot projects have shown promise in achieving these goals, even under the current budgetary constraints.
PMCID: PMC1382120  PMID: 7610217
10.  Stakeholder perceptions of a nurse led walk-in centre 
Background
As many countries face primary care medical workforce shortages and find it difficult to provide timely and affordable care they seek to find new ways of delivering first point of contact health care through developing new service models. In common with other areas of rural and regional Australia, the Australian Capital Territory (ACT) is currently experiencing a general practitioner (GP) workforce shortage which impacts significantly on the ability of patients to access GP led primary care services. The introduction of a nurse led primary care Walk-in Centre in the ACT aimed to fulfill an unmet health care need in the community and meet projected demand for health care services as well as relieve pressure on the hospital system. Stakeholders have the potential to influence health service planning and policy, to advise on the potential of services to meet population health needs and to assess how acceptable health service innovation is to key stakeholder groups. This study aimed to ascertain the views of key stakeholders about the Walk-in Centre.
Methods
Stakeholders were purposively selected through the identification of individuals and organisations which had organisational or professional contact with the Walk-in Centre. Semi structured interviews around key themes were conducted with seventeen stakeholders.
Results
Stakeholders were generally supportive of the Walk-in Centre but identified key areas which they considered needed to be addressed. These included the service's systems, full utilisation of the nurse practitioner role and adequate education and training. It was also suggested that a doctor could be available to the Centre as a source of referral for patients who fall outside the nurses' scope of practice. The location of the Centre was seen to impact on patient flows to the Emergency Department.
Conclusion
Nurse led Walk-in Centres are one response to addressing primary health care medical workforce shortages. Whilst some stakeholders have reservations about the model others are supportive and see the potential the model has to provide accessible primary health care. Any further developments of nurse-led Walk-in Centres need to take into account the views of key stakeholders so as to ensure that the model is acceptable and sustainable.
doi:10.1186/1472-6963-12-382
PMCID: PMC3529673  PMID: 23126431
11.  Health problems and health care for adolescents in residential facilities in Quebec. 
Canadian Medical Association Journal  1977;117(12):1403-1406.
The health problems of 160 adolescents in four residential facilities of the Quebec social welfare court were studied. At the time of admission 44% had at least one problem requiring consultation with a specialist and 80% had an average of two problems requiring primary care. The medical records of 106 youngsters in two re-education centres were also reviewed and similar results were noted. The health services available, particularly physical examination and laboratory testing at the time of admission and arrangements for referral and follow-up were judged to be insufficient in most centres. Although society has taken custody of these adolescents, no one is responsible for their health care. Since February 1976 the social welfare court residential facilities and the network involved in the care of socially disturbed youngsters have been undergoing reorganization. Health programs and services ought to be part of this reorganization, and private physicians, hospitals and government each should have a role in the establishment and functioning of these programs.
PMCID: PMC1880395  PMID: 589541
12.  Planning elderly and palliative care in Montenegro 
Introduction
Montenegro, a newly independent Balkan state with a population of 650,000, has a health care reform programme supported by the World Bank. This paper describes planning for integrated elderly and palliative care.
Description
The current service is provided only through a single long-stay hospital, which has institutionalised patients and limited facilities. Broad estimates were made of current financial expenditures on elderly care. A consultation was undertaken with stakeholders to propose an integrated system linking primary and secondary health care with social care; supporting people to live, and die well, at home; developing local nursing homes for people with higher dependency; creating specialised elderly-care services within hospitals; and providing good end-of-life care for all who need it. Effectiveness may be measured by monitoring patient and carers’ perceptions of the care experience.
Discussion
Changes in provision of elderly care may be achieved through redirection of existing resources, but the health and social care services also need to enhance elderly care budgets. The challenges for implementation include management skills, engaging professionals and political commitment.
Conclusion
Middle-income countries such as Montenegro can develop elderly and palliative care services through redirection of existing finance if accompanied by new service objectives, staff skills and integrated management.
PMCID: PMC2691939  PMID: 19513178
planning; elderly; palliative care; economics; Europe
13.  Partnership at the Forefront of Change: Documenting the Transformation of Child and Youth Mental Health Services in Quebec 
Objective:
The Quebec Plan d’action en santé mentale (PASM) (Mental Health Action Plan) reform, a major transformation of the province’s mental health care system, has put primary care rather than hospital-based care at the forefront of mental health service delivery. This study documents perceptions of changes in child and youth mental health (CYMH) services following the reform, as well as facilitators and obstacles to collaboration and partnership in CYMH services, and the specific challenges related to collaboration and partnership when servicing multi-ethnic populations.
Methods:
This qualitative participatory research study collected data using semi-structured individual interviews, focus groups and participant observation in community-based health and social service institutions. Thematic analysis was performed.
Results:
The reform process encountered challenges in building a common culture of care within and between institutions, while collaboration and partnership evolved in a positive direction throughout the study. Study results highlighted the importance of fostering communication at all levels. Collaboration and partnership was facilitated by opportunities for clinical discussions, dialogue on models of care, harmonizing administrative and clinical priorities, and involving key actors and structures. The results revealed difficulties in implementing multidisciplinary work and in negotiating partners’ responsibilities. Quality of partnership and collaboration appeared particularly crucial in providing optimal care to vulnerable families, including migrants.
Conclusion:
The PASM reform involved a major and challenging transformation in CYMH services. Continuous dialogue through time and leadership sharing appeared promising to foster this transformation.
PMCID: PMC3338174  PMID: 22548105
collaboration; partnership; youth mental health; child and adolescent psychiatry; family; collaboration; partenariat; santé mentale des enfants et adolescents; psychiatrie de l’enfant et de l’adolescent; famille
14.  System Factors Affect the Recognition and Management of Post-Traumatic Stress Disorder by Primary Care Clinicians 
Medical care  2009;47(6):686-694.
Background
Post-traumatic stress disorder (PTSD) is common with an estimated prevalence of 8% in the general population and up to 17% in primary care patients. Yet, little is known about what determines primary care clinician’s (PCC) provision of PTSD care.
Objective
To describe PCC’s reported recognition and management of PTSD and identify how system factors affect the likelihood of performing clinical actions with regard to patients with PTSD or “PTSD treatment proclivity.”
Design
Linked cross-sectional surveys of medical directors and PCCs.
Participants
Forty-six medical directors and 154 PCCs in community health centers (CHCs) within a practice-based research network in New York and New Jersey.
Measurements
Two system factors (degree of integration between primary care and mental health services, and existence of linkages with other community, social, and legal services) as reported by medical directors, and PCC reports of self-confidence, perceived barriers, and PTSD treatment proclivity.
Results
Surveys from 47 (of 58) medical directors (81% response rate) and 154 PCCs (86% response rate). PCCs from CHCs with better mental health integration reported greater confidence, fewer barriers, and higher PTSD treatment proclivity (all p<.05). PCCs in CHCs with better community linkages reported greater confidence, fewer barriers, higher PTSD treatment proclivity, and lower proclivity to refer patients to mental health specialists or to use a “watch and wait” approach (all p<.05).
Conclusion
System factors play an important role in PCC PTSD management. Interventions are needed that restructure primary care practices by making mental health services more integrated and community linkages stronger.
doi:10.1097/MLR.0b013e318190db5d
PMCID: PMC2762995  PMID: 19433999
. Primary care; post-traumatic stress disorder (PTSD); system factors; barriers
15.  From organizational integration to clinical integration: analysis of the path between one level of integration to another using official documents 
Purpose
Services’ integration comprises organizational, normative, economic, informational and clinical dimensions. Since 2004, the province of Quebec has devoted significant efforts to unify the governance of the main health and social care organizations of its various territories. Notwithstanding the uniformity of the national plan’s prescription, the territorial integration modalities greatly vary across the province.
Theory
This research is based upon a conceptual model of integration that comprises six components: inter-organizational partnership, case management, standardized assessment, a single entry point, a standardized service planning tool and a shared clinical file.
Methods
We conducted an embedded case study in six contrasted sites in terms of their level of integration. All documents prescribing the implementation of integration were retrieved and analyzed.
Results and conclusions
The analyzed documents demonstrate a growing local appropriation of the current integrative reform. Interestingly however, no link seems to exist between the quality of local prescriptions and the level of integration achieved in each site. This finding leads us to hypothesize that the variable quality of the operational accompaniment offered to implement these prescriptions is a variable in play.
PMCID: PMC3031828
clinical integration; innovation
16.  Care for Canada's frail elderly population: Fragmentation or integration? 
Budget constraints, technological advances and a growing elderly population have resulted in major reforms in health care systems across Canada. This has led to fewer and smaller acute care hospitals and increasing pressure on the primary care and continuing care networks. The present system of care for the frail elderly, who are particularly vulnerable, is characterized by fragmentation of services, negative incentives and the absence of accountability. This is turn leads to the inappropriate and costly use of health and social services, particularly in acute care hospitals and long-term care institutions. Canada needs to develop a publicly managed community-based system of primary care to provide integrated care for the frail elderly. The authors describe such a model, which would have clinical and financial responsibility for the full range of health and social services required by this population. This model would represent a major challenge and change for the existing system. Demonstration projects are needed to evaluate its cost-effectiveness and address issues raised by its introduction.
PMCID: PMC1228270  PMID: 9347783
17.  Reforming healthcare systems on a locally integrated basis: is there a potential for increasing collaborations in primary healthcare? 
Background
Over the past decade, in the province of Quebec, Canada, the government has initiated two consecutive reforms. These have created a new type of primary healthcare – family medicine groups (FMGs) – and have established 95 geographically defined local health networks (LHNs) across the province. A key goal of these reforms was to improve collaboration among healthcare organizations. The objective of the paper is to analyze the impact of these reforms on the development of collaborations among primary healthcare practices and between these organisations and hospitals both within and outside administrative boundaries of the local health networks.
Methods
We surveyed 297 primary healthcare practices in 23 LHNs in Quebec’s two most populated regions (Montreal & Monteregie) in 2005 and 2010. We characterized collaborations by measuring primary healthcare practices’ formal or informal arrangements among themselves or with hospitals for different activities. These collaborations were measured based on the percentage of clinics that identified at least one collaborative activity with another organization within or outside of their local health network. We created measures of collaboration for different types of primary healthcare practices: first- and second-generation FMGs, network clinics, local community services centres (CLSCs) and private medical clinics. We compared their situations in 2005 and in 2010 to observe their evolution.
Results
Our results showed different patterns of evolution in inter-organizational collaboration among different types of primary healthcare practices. The local health network reform appears to have had an impact on territorializing collaborations firstly by significantly reducing collaborations outside LHNs areas for all types of primary healthcare practices, including new type of primary healthcare and CLSCs, and secondly by improving collaborations among healthcare organizations within LHNs areas for all organizations. This is with the exception of private medical clinics, where collaborations decreased both outside and within LHNs.
Conclusion
Health system reforms aimed at creating geographically based networks influenced primary healthcare practices’ both among themselves (horizontal collaborations) and with hospitals (vertical collaborations). There is evidence of increased collaborations within defined geographic areas, particularly among new type of primary healthcare.
doi:10.1186/1472-6963-13-262
PMCID: PMC3750424  PMID: 23835105
Primary care; Network; Inter-organization collaboration
18.  The Health of the James Bay Cree 
Canadian Family Physician  1988;34:1606-1613.
The health of the James Bay Cree of Quebec reflects their history and environment. Their ancestors were living in Northern Quebec for centuries before the Europeans arrived bringing new infectious diseases and developing a health-care structure that has relegated traditional Cree medicine to the background. The James Bay and Northern Quebec Agreement of 1975 led to the creation of the Cree Board of Health and Social Services under the Quebec Ministry of Health. Various changes have resulted in the eight Cree villages over the past 15 years, both in the socio-economic situation and in the health status of the Cree. Improvements in health will come about through increased participation of Native people in the delivery and control of health services, more accessible health services, and the creation of healthy and health-promoting environments.
PMCID: PMC2218170  PMID: 21253035
Traditional medicine; James Bay Cree; Northern and Native health
19.  Improving cancer surgery in Ontario: recommendations from a strategic planning retreat 
Canadian Journal of Surgery  2004;47(4):270-276.
Introduction
The Ministry of Health and Long-Term Care mandated a rapid and thorough change in the delivery of cancer services in Ontario to integrate ambulatory services offered by Cancer Care Ontario (CCO) with the inpatient services of affiliated hospitals. The CCO Surgical Oncology Program held a strategic planning retreat to establish the basis upon which to implement surgery-specific changes.
Methods
Participants completed a pre-retreat survey. Based on survey results, the retreat was organized around 4 themes: role of the Surgical Oncology Program; knowledge transfer; funding for cancer surgery; and research priorities. These topics were discussed in small breakout groups and by the entire assembly.
Results
Retreat participants (n = 55) included hospital CEOs, vice-presidents of cancer services, surgeons from cancer centres and community hospitals, academic chairs of surgery, clinician researchers and managers from CCO. Responses to the pre-retreat survey (n = 38) and recommendations made by retreat participants showed strong support for the Surgical Oncology Program to take a leadership role in the development and monitoring of quality indicators, research related to cancer surgery and the creation of regional communities of practice. Funding mechanisms for cancer surgeons and hospitals performing cancer surgery were also highlighted.
Conclusion
The Surgical Oncology Program used the results to develop a strategic plan that was approved by retreat participants and the board of the CCO. The program has embarked on a multifaceted approach to facilitate, monitor and report on the organization and delivery of cancer surgery in Ontario.
PMCID: PMC3211788  PMID: 15362329
20.  Integrated delivery systems: has their time come in Canada? 
In the 1990s every Canadian province is struggling to reduce health care expenditures without jeopardizing access to health care or quality of care. The authors propose a new model for health care delivery: the Canadian Integrated Delivery System (CIDS). A CIDS is a network of health care organizations; it would provide, or arrange to provide, a coordinated continuum of services to a defined population and would be held clinically and fiscally accountable for the outcomes in and health status of that population. A CIDS would serve 100,000 to 2 million people; the care it would provide would be funded on a capitation basis. For providers, there would be explicit financial incentives to minimize costs. At the same time, service quality and consumer choice of primary care practitioner would be maintained. Primary care physicians and specialists would work with other health care service providers to offer a full spectrum of care. CIDS providers would form strategic alliances with community agencies, hospitals, the private sector and other health care services not managed by the CIDS, as needed. For physicians, affiliation with a CIDS that provided strong clinical leadership could be beneficial to their income stability and autonomy. Pilot projects of this model in several communities would determine whether this concept is feasible in the Canadian health care context.
PMCID: PMC1487797  PMID: 8634958
21.  Region Emilia Romagna: Primary Health Care Integration/Regione Emilia-Romagna: l’integrazione nel sistema di Cure Primarie 
The politics of Region Emilia-Romagna have been meant to improve social and health care integration through an architecture of local services coherent with this purpose, setting up a Department dedicated to Primary Care inside the Social and Health District.
The territorial basis of the Local Health Units (LHU), the resident people, the sustained public spending, the employed human resources and the provided services all delineate the organization of the LHU. The purpose is to grant strong integration among local bodies and LHUs through a governance system (planning, management and administration) that makes a distinction between commissioning and supply. The Committenza (commissioning department), which reports to the Strategic Direction and the District, directs the offer in connection with the need analysis, whereas the Primary Care Department arranges activities and provides services by means of integrated networks which ensure continuity to the care.
The main hub in the network is known as the Casa della Salute (House of Health), which works through structured practices, protocols and procedures. LHU professionals and freelancers under contract supply primary, in-home and nursing home care, plus specialist outpatient treatment.
The Casa della Salute, whose size will depend on the context (large, medium and small), are reliable reference points for citizens, who can address to them in every moment of the day.
On behalf of the Regione Emilia-Romagna, it is the Primary Care Observatory which registers the functions existing in the 42 Houses of Health and their organizational and structural characteristics. The analysis of the obtained data will increase enhance the Houses’ implementation.
PMCID: PMC3617754
Emilia Romagna; health care integration; primary care observatory
22.  Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial 
Background
Chronic diseases represent a major challenge for health care and social services. A number of people with chronic diseases require more services due to characteristics that increase their vulnerability. Given the burden of increasingly vulnerable patients on primary care, a pragmatic intervention in four Family Medicine Groups (primary care practices in Quebec, Canada) has been proposed for individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory diseases, musculoskeletal diseases and/or chronic pain) who are frequent users of hospital services. The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program. The goals of this study are to: (1) analyze the implementation of the intervention in the participating practices in order to determine how the various contexts have influenced the implementation and the observed effects; (2) evaluate the proximal (self-efficacy, self-management, health habits, activation and psychological distress) and intermediate (empowerment, quality of life and health care use) effects of the intervention on patients; (3) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention.
Methods/Design
The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders (Family Medicine Group and health centre management, Family Medicine Group practitioners, patients and their families, health centre or community partners). The data will be obtained through individual and group interviews, project documentation reviews and by documenting the intervention. Evaluation of the effects on patients will be based on a pragmatic randomized before-after experimental design with a delayed intervention control group (six months). Economic analysis will include cost-effectiveness and cost-benefit analysis.
Discussion
The integration of a case management intervention delivered by nurses and self-management group support into primary care practices has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care. Decision-makers, managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practices in the region and elsewhere.
Trial Registration
NCT01719991
doi:10.1186/1472-6963-13-49
PMCID: PMC3601974  PMID: 23391214
Chronic diseases; Primary care; Family Medicine Group; Frequent users; Case management; Self-management; Primary care nursing; Services integration
23.  The History of Successful Community-Operated Health Services in Kahnawake, Quebec 
Canadian Family Physician  1988;34:2167-2169.
Kateri Memorial Hospital Centre (KMHC) provides well-integrated and high-quality acute care and preventive health services for the Mohawk Community of Kahnawake, Quebec, with its population of 5409 persons (1985). Since 1955, the hospital centre has been administered and largely staffed by the community. This article describes the history of the development of health services, discusses why this venture has been so successful, and acknowledges some of the problems. It is hoped that our experiences will benefit, first, other Native communities that are interested in gaining control of their own health services and, secondly, non-Indian staff who provide professional care.
PMCID: PMC2219181  PMID: 21253246
Native health care; community health services; hospital centre
24.  Primary and managed care. Ingredients for health care reform. 
Western Journal of Medicine  1994;161(1):78-82.
The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.
PMCID: PMC1011384  PMID: 7941522
25.  Priorités dans le domaine de la santé au Québec 
Canadian Medical Association Journal  1977;116(9):1074-1085.
The reform of health services in Quebec, of which the most important stage was the creation of the Department of Social Affairs and the Quebec Health Insurance Board, has solved certain problems such as the inaccessibility to care because of the cost, the paucity of medical personnel and the excessive increase in the cost of the services offered to hospital patients. A critical analysis of both the reform and its practical consequences points to certain conclusions which, far from rejecting the principle of the reform, indicate none the less various possibilities for reorienting its priorities. Observing the rate of recourse to health services as well as the attitudes and conduct of health professionals have helped us to identify the causes of certain tendencies inspired by the incentives inherent in the reform. The organization of health services in Quebec must be oriented toward new priorities: the prevention and treatment both of environmental diseases and diseases associated with ageing plus the definition of a global approach to public health.
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PMCID: PMC1879068  PMID: 870160

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