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1.  The path dependency theory: analytical framework to study institutional integration. The case of France 
Background
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.
Purpose
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.
Methods
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.
Results
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.
Conclusion
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.
PMCID: PMC2916113  PMID: 20689740
integrated care; institutional integration; path dependence; gerontology
2.  Is the PRISMA-France glass half-full or half-empty? The emergence and management of polarized views regarding an integrative change process 
Aim
The PRISMA-France pilot project is aimed at implementing an innovative case management type integration model in the 20th district of Paris. This paper apprehends the emergence of two polarized views regarding the progression of the model's spread in order to analyze the change management enacted during the process and its effects.
Method
A qualitative analysis was conducted based on an institutional change model.
Results
Our results suggest that, according to one view, the path followed to reach the study's current level of progress was efficient and necessary to lay the foundation of a new health and social services system while according to the other, change management shortcomings were responsible for the lack of progress.
Discussion
While neither of these two views appears entirely justified, analyzing the factors underlying their differences pinpoints some of the challenges involved in managing the spread of an integrated service delivery network. Meticulous preparation for the change management role and communication of the time and effort required for a wholesale institutional change process may be significant factors for a successful integrative endeavor.
PMCID: PMC2807121  PMID: 20087426
change management; institutional change; integrated care; networks
3.  You want us to manage cases, never! Love, hate and paradoxes of the relationship of social workers with the notion of case management 
Purpose
This communication concerns the renewal of case management in favour of the aspiration to link management and intervention in a services' integration device. Three main sections are encompassed in this communication. The first consists of a brief presentation of the history and foundations of case management, the second of an analysis of the receptiveness of the primary-adoptants of a pilot-study in France to a Quebecois case management model and the last of a proposition to reproblematize questions concerning the relation between management and intervention.
Methods
This presentation is based upon a transversal observation of results of qualitative studies concerning the reception of the notion of case management by social workers. The data were composed of discursive material collected from three studies (two from Québec and one from France) with social workers who recently engaged in case management.
Results and conclusions
Even though case management arose from the patrimony of social work, its renewal raises concerns in terms of rationalization, medicalization and systematization of the discipline. These fears are partly compensated by the hope that this new function will allow social workers to base their interventions with complex clinical cases on an interdisciplinary solidarity.
PMCID: PMC2807070
case management; social workers
4.  Attributes of conception of relational continuity: an essential component of the integration of services for frail older people 
Purpose
Present the results of an exploratory study which aimed to identify the attributes of relational continuity as conceived by the actors involved in the organization of services to frail older people.
Theory
The lengthening of the duration of life with autonomy loss warrants a transformation of the response to the needs of older people. The organization of services must evolve from a hospital-centered model to a residence-centered model better adapted to long-term care. This refocus on residential care provokes a multiplication of service providers which must be coordinated to ensure continuity of care [1]. Amongst the three forms of continuity (informational, management and relational) [2], relational continuity appears as the least documented and most difficult to measure.
Methods
Twenty-seven interviews with practitioners, managers, family caregivers and users were conducted and analysed using a content analysis approach.
Results and conclusions
While the family caregivers and users stressed the psycho-affective nature of the care relationship, the practitioners viewed it as a means to ensure the adequacy of services. From the user's viewpoint, the relationship is not the responsibility of one professional, but of a collective effort that may carry his voice across the services organization.
PMCID: PMC2807069
frail older people; relational continuity; service integration
5.  Institutional integration, health and social care policy and social welfare: an application of the ‘path dependence’ theory in France 
Introduction
The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. The PRISMA France study aims to investigate the implementation of this model, which relies on the establishment of advisory boards at institutional, organisational and professional levels of decision-making, in France. These boards are guided by whole systems thinking and function in a joined-up, co-ordinated manner.
Method
A qualitative approach was adopted to study the model's implementation. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings and administrative documentations. Validity was insured by triangulation methods and content saturation.
Results
Our analyses revealed the complexity, instability and fragmentation of the institutional governance of publics policies for elderly people. The ‘path dependence’ to the Bismarckian system and the incomplete reforms of gerontological policies generate a cohabitation of three concurrent policies (national, regional and local) and a juxtaposition of two institutional systems (health and social care policy and social welfare). In such a context, no institution possesses sufficient authority to determine gerontological policy.
Conclusion
In the light of these analyse, the particularly complex and time-consuming implementation of the PRISMA model in France can be better understood.
PMCID: PMC2807065
path dependency; public policies; integrated health care networks; France
6.  The PRISMA France study: implementation rate and factors influencing this rate 
Introduction
The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. In the PRISMA-France study, we qualitatively studied the implementation process of this model in French settings.
Method
Our analyses were based on in-depth interviews, meeting observations and the documentation produced.
Results
We adapted the implementation scale inherent to the PRISMA model to fit the French context and, using this scale, were able to appreciate a 15% progression of implementation, from 5% to 20%, in the first 18 months of the study. The factors that contributed to this rate of progression are of three main types. To begin with, contextual factors intrinsic to the French setting complexified the incorporation of integration into the public policy agenda and the means to achieve this feat. Secondly, factors related to the background of the concerned managers and professionals were identified. Thirdly, factors related to the particularities of the PRISMA-Experiment's governance were noted. Our experience leads to consider time as the answer to these hindering contextual, professional and governance issues.
Conclusion
These observations hold an important strategic value in a time where a wider integration experimentation is planned by the ‘plan-Alzheimer’ in France.
PMCID: PMC2807061
integration measurement; factors influencing implementation; integrated health care networks; France
7.  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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