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1.  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
2.  Study of the composition of the various forms of coordination in the case management practice 
Purpose
In 2004, Quebec’s Health and Social Care Ministry implemented an integrative reform aiming to systematize coordination which employed prescriptive devices. The will to systematize coordination practices is supported by formal coordination devices, such as case management. However, many obstacles lay in the path of these devices’ usage.
Theory
This presentation is based on Boltanski and Thévenot’s (1991) theory of conventions. This theory was utilized to analyze the operations that lead to the convened agreements which serve coordination in its formal and emergent aspects.
Methods
We utilized a qualitative and exploratory embedded case study design in which we employed three data collection and analysis methods: a documentary analysis of the integrative prescriptions, interviews aiming to make explicit the concrete coordination practices and direct observation of professional practices.
Results and conclusions
We identified different types of coordination systems in case management practices. Notably, the so-called ‘peri-professional’ system that grants the family caregivers the role of intermediate between the frail elder and the health and social care network, as well as the so-called ‘virtual’ system produced by the technological means of the computerized clinical files.
PMCID: PMC3031801
case management; coordination
3.  Studying integrated health care systems with a structurationist approach 
Introduction
To implement an integrated health care system is not an easy task and to ensure its sustainability is yet more difficult.
Aim
Discuss how a structurationist approach can shed light on the stakes of these processes and guide the managers of such endeavours.
Theory and method
Structuration theory [1] has been used by numerous authors to cast new light on complex organizational phenomena. One of the central tenets of this theory is that social systems, such as integrated health care systems, are recurrent social practices across time-space and are characterized by structural properties which simultaneously constrain and enable the constitutive social actors who reproduce and transform the system through their practices. We will illustrate our theoretical standpoint with empirical material gathered during the study of an integrated health care system for the frail elderly in Quebec, Canada. This system has been implemented in 1997 and is still working well in 2010.
Results and conclusion
To implement an integrated health care system that is both effective and sustainable, its managers must shrewdly allow for the existing system and progressively introduce changes in the way managers and practitioners at work in the system view their role and act on a daily basis.
PMCID: PMC3031804
integration; structuration; health care system; frail elderly; Canada
4.  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
5.  Contributions of family caregivers to the coordination of services for the frail elderly 
Purpose
This presentation concerns the contribution of family caregivers to the coordination of services for the frail elderly.
Theory
The role of family caregivers is partly conditioned by the conjuncture of health and social care organization. In recent years, many efforts were devoted to the creation of services integration devices which aim to improve user experience in particularly fragmented services organization [1]. In this context, family caregivers increasingly draw from their personal resources to care for their loved ones. In fact, Ducharme and colleagues [2] estimated that 80% of the care received is dispensed by family caregivers. Therefore, a better understanding of the contribution of family caregivers to coordinated care was deemed pertinent.
Methods
Our exploratory study consisted of 12 interviews with family caregivers and frail elderly users concerning their coordination experience.
Results and conclusions
In all circumstances, family caregivers have an important contribution to coordination. In fact, they absorb the coordination surplus required during the pre-installation phase of case management or during the users' episodes of transforming needs. This reveals a temporal gap between the need for coordination and the effective deployment of case management. Therefore, they appear as the primary bearers of services coordination.
PMCID: PMC2807057
frail older people; family caregivers

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