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.
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.
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.
Integrated care; integrated health care delivery; primary care; regionalised health services; integrated care models
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.
integration; merger; health and social services; integrated care; Canada
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.
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.
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.
PRISMA; integrated health and social services; Canada; public insurance; long-term care; structural integration
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.
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.
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.
integrated service networks; integration strategies; mental health network models; Quebec (Canada) mental health system
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.
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.
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).
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.
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.
Understanding Health systems have now become the priority focus of researchers and policy makers, who have progressively moved away from a project-centred perspectives. The new tendency is to facilitate a convergence between health system developers and disease-specific programme managers in terms of both thinking and action, and to reconcile both approaches: one focusing on integrated health systems and improving the health status of the population and the other aiming at improving access to health care. Eye care interventions particularly in developing countries have generally been vertically implemented (e.g. trachoma, cataract surgeries) often with parallel organizational structures or specialised disease specific services. With the emergence of health system strengthening in health strategies and in the service delivery of interventions there is a need to clarify and examine inputs in terms governance, financing and management. This present paper aims to clarify key concepts in health system strengthening and describe the various components of the framework as applied in eye care interventions.
Global eye health; health interventions; health systems; systems thinking
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.
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.
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.
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.
Despite of an insignificant track record of quasi market models in Sweden, new models of this kind have recently been introduced in health care; commonly referred to as ‘choice of care’. This time citizens act as purchasers; choosing the primary care centre or family physician they want to be treated by, which, in turn, generates a capitation payment to the chosen unit. Policy makers believe that such systems will be self-remedial, that is, as a result of competition the strong providers survive while unprofitable ones will be eliminated. Because of negative consequences of the fragmented health care delivery, policy makers at the same time also promote different forms of integrated health care arrangements. One example is ‘local health care’, which could be described as an upgraded community-oriented primary care, supported by adaptable hospital services, fitting the needs of a local population. This paper reviews if it is possible to combine this kind of integrated care system with a competition driven model of governance, or if they are incompatible.
Inter-organisational and interprofessional collaboration, accessibility of services, and provider continuity.
Results and conclusions
The findings indicate that some choice of care schemes could hamper the development of integration in local health care. However, geographical monopolies like local health care, enclosed in a non-competitive context, lack the stimulus of competition that possibly improves performance. Thus, it could be argued that if choice of care and local health care should be combined, patients ought to choose between integrated health care arrangements and not among individual health professionals.
patient choice; local health care; health care policy; Sweden
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.
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.
Traditional medicine; James Bay Cree; Northern and Native health
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.
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.
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.
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.
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.
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.
Native health care; community health services; hospital centre
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.
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.
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.
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.
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
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.
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.
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.”
Linked cross-sectional surveys of medical directors and PCCs.
Forty-six medical directors and 154 PCCs in community health centers (CHCs) within a practice-based research network in New York and New Jersey.
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.
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).
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.
. Primary care; post-traumatic stress disorder (PTSD); system factors; barriers
Increasing numbers of women are entering medicine in Canada. In 1959 women accounted for 6% of the medical school graduates, but by 1989 they accounted for 44%. Although there has been little systematic investigation of the impact of this increase on Canada's health care system, there are grounds for believing that female physicians bring with them distinctive values and interests, which may be reflected in the way they conduct their professional practices. We used data from a recent national survey of 2398 Canadian physicians to examine differences between women and men in their practices and their attitudes toward health care issues. Significant differences were found in the organization and management of the practices. Women preferred group over solo practice and were overrepresented in community health centres, health service organizations and centres locaux de services communautaires in Quebec. One-third of the women, as compared with half of the men, were in specialties. Even after adjusting for differences in workloads the incomes of the women were significantly lower than those of the men. Only minor differences were observed in the assessment of the health care system and alternative modes of organizing health care services. We believe that the differences were due to the double workload of women as professionals and family caregivers and the powerful socialization effects of medical education. As women overcome their minority status in the medical profession, differences between the sexes may become more apparent. Thus, the extent and effects of the progressive increase in the number of women in Canadian medicine should be assessed on an ongoing basis.
The literature on integration indicates the need for an enhanced theorization of institutional integration. This article proposes path dependence as an analytical framework to study the systems in which integration takes place.
PRISMA proposes a model for integrating health and social care services for older adults. This model was initially tested in Quebec. The PRISMA France study gave us an opportunity to analyze institutional integration in France.
A qualitative approach was used. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings, and administrative documents.
Our analyses revealed the complexity and fragmentation of institutional integration. The path dependency theory, which analyzes the change capacity of institutions by taking into account their historic structures, allows analysis of this situation. The path dependency to the Bismarckian system and the incomplete reforms of gerontological policies generate the coexistence and juxtaposition of institutional systems. In such a context, no institution has sufficient ability to determine gerontology policy and build institutional integration by itself.
Using path dependence as an analytical framework helps to understand the reasons why institutional integration is critical to organizational and clinical integration, and the complex construction of institutional integration in France.
integrated care; institutional integration; path dependence; gerontology
Recent trends place an emphasis on school health care, the ultimate goal of which is to protect, maintain, and promote students' health. School health care is a program that integrates health care services, health education, health counseling, and local social health services. The student health examination (SHE) system is a part of school health care and schools and communities must be available to provide professional health services. Pediatricians also have important roles as experts in both school health care and the SHE system. In this article, the history of school health care, its legal basis, and the current status of the SHE system in Korea are reviewed. Furthermore, sample surveys from the past few years are reviewed. Through this holistic approach, future directions are proposed for the improvement of SHE and school health care.
School health care; School health examination; Student health examination
In 2005, the State of New Mexico undertook a sweeping transformation of all publicly funded behavioral health services. The reform was intended to enhance the cultural responsiveness and appropriateness of these services. To examine achievement of this objective, we conducted a qualitative study of the involvement of Native Americans in reform efforts and the subsequent impacts of reform on services for Native Americans. We found that the reform was relatively unsuccessful at creating mechanisms for genuine community input or improving behavioral health care for this population. These shortcomings were related to limited understandings of administrators concerning how tribal governments and health care systems operate, and the structural limitations of a managed care system that does not allow flexibility for culturally appropriate utilization review, screening, or treatment. However, interaction between the State and tribes increased, and we conclude that aspects of the reform could be strengthened to achieve more meaningful involvement and service improvements.
Aboriginal people; North America; evidence-based practice; health care disparities; health care; access to; health care; remote / rural; health policy / policy analysis; mental health and illness
This paper analyzes progress made toward the integration of the French health care system for the older and chronically ill population.
Over the last 10 years, the French health care system has been principally influenced by two competing linkage models that failed to integrate social and health care services: local information and coordination centers, governed by the social field, and the gerontological health networks governed by the health field. In response to this fragmentation, Homes for the Integration and Autonomy for Alzheimer patients (MAIAs) is currently being implemented at experimental sites in the French national Alzheimer plan, using an evidence-based model of integrated care. In addition, the state’s reforms recently created regional health agencies (ARSs) by merging seven strategic institutions to manage the overall delivery of care.
The French health care system is moving from a linkage-based model to a more integrated care system. We draw some early lessons from these changes, including the importance of national leadership and governance and a change management strategy that uses both top-down and bottom-up approaches to implement these reforms.
France; health and social integration; gerontology
Mexico is undergoing profound health reform, extending health insurance to previously uninsured populations and changing the way health care services are delivered. Legislation enacted in 2003 and implemented in 2004 mandated funding and infrastructure that will allow 52% of Mexico's population to access medical care at no cost by 2010. This ambitious social reform has not been without challenges, particularly financial sustainability. Health promotion, because of its potential to prevent or delay chronic diseases and injuries and their associated costs, is a key component of health care reform (1).
In 2006, the Ministry of Health's General Directorate of Health Promotion developed the Health Promotion Operational Model. Based on Ottawa Charter functions, the model integrates health promotion activities within the overall health care system. The main goal of this model is to build strong human capital and to improve organizational capacity for health promotion starting at the local level by training health care personnel to implement health promotion activities. Organizational development workshops started in 2006, and implementation plans in all 32 Mexican states were in place by end of 2008 (2).