Analyse d’implantation de la gestion de cas des grands utilisateurs de services de santé dans un groupe de médecine familiale au Saguenay-Lac-Saint-Jean

Une faible proportion de la population génère une majeure partie des coûts de soins de santé. Souvent, cette population est caractérisée comme ayant des besoins complexes et compte des grands utilisateurs de services de santé (GU). Cette utilisation accrue des services engendre des soins non optimaux et des répercussions néfastes sur le système de la santé. Il importe donc de diriger cette population vers les services répondant a leurs besoins. La gestion de cas (GC) est une des interventions les plus efficaces pour prendre en charge les GU. A plusieurs égards, les bienfaits de cette intervention auprès des GU ont été prouvés dans la littérature. Dans la région du Saguenay-Lac-Saint-Jean (SLSJ), le Centre intégré universitaire de santé et de services sociaux (CIUSSS) a entrepris d’implanter cette intervention au sein de groupes de médecine de famille (GMF) lors de l’implantation d’une démarche intégrée de gestion des maladies chroniques en première ligne (DIMAC02, volet 2) en impliquant les infirmières et les travailleuses sociales (TS). Toutefois, implanter une telle innovation est un processus complexe impliquant plusieurs facteurs, a plusieurs niveaux. A ce sujet, la littérature reste succincte et peu d’éléments sont rapportés sur l’implantation de la GC des GU en première ligne. De plus, le partage du rôle de GC entre les infirmières et les TS est aussi peu documenté. Considérant le manque de connaissance sur les facteurs a considérer lors de l’implantation de la GC, il importe d’analyser cette implantation. Ce mémoire a donc pour but d’explorer l’implantation de la gestion de cas des GU de services hospitaliers au sein d’une dyade infirmière/travailleuse sociale dans un GMF implique dans le projet clinique D1MAC02 (volet 2) au SLSJ. Plus particulièrement, les objectifs sont de préciser les facteurs facilitants et les barrières à l’implantation et d’explorer le partage du rôle de GC dans la dyade infirmière/TS. Une étude de cas unique selon l’approche de Yin (2018) a été réalisée dans un GMF de la région du SLSJ. Plusieurs méthodes de collecte des données furent utilisées : entrevues individuelles; observation participante; analyse documentaire et tenue d’un journal de bord. Une analyse thématique mixte inductive-déductive à l’aide du cadre théorique de Chaudoir, Dugan et Barr (2013) a révèle plusieurs facteurs ayant influence l’implantation. Les barrières à l’implantation ont été : le contexte sociopolitique (loi 10, loi 20 et le nouveau cadre de gestion des GMF); le défi de l’adhésion médicale et psychosociale; des lacunes au niveau des facteurs organisationnels (accès à l’information, communication, collaboration); et le manque de clarté du rôle. Du côté des facteurs facilitants, l’apport du gestionnaire de cas du CIUSSS a pallié plusieurs barrières et était essentiel à la GC des GU en GMF. Il a également été décrit parmi ceux-ci l’attitude positive des intervenants, la proximité des professionnels à l’intérieur du GMF, l’adoption d’une routine collaborative hebdomadaire et la présence d’expériences cliniques antérieures. Le partage des rôles entre l’infirmière et la TS s’est effectué autour du type de problématiques des GU et la complémentarité des rôles est à promouvoir. Améliorer l’implantation en considérant ces facteurs aura un impact sur son succès et optimisera le rôle de l’infirmière au sein de l’équipe interprofessionnelle

Key factors of case management interventions for frequent users of healthcare services : a thematic analysis review

Objective : The aim of this paper was to identify the key factors of case management (CM) interventions among frequent users of healthcare services found in empirical studies of effectiveness. Design : Thematic analysis review of CM studies. Methods : We built on a previously published review that aimed to report the effectiveness of CM interventions for frequent users of healthcare services, using the Medline, Scopus and CINAHL databases covering the January 2004–December 2015 period, then updated to July 2017, with the keywords ‘CM’ and ‘frequent use’. We extracted factors of successful (n=7) and unsuccessful (n=6) CM interventions and conducted a mixed thematic analysis to synthesise findings. Chaudoir’s implementation of health innovations framework was used to organise results into four broad levels of factors: (1) ,environmental/organisational level, (2) practitioner level, (3) patient level and (4) programme level. Results : Access to, and close partnerships with, healthcare providers and community services resources were key factors of successful CM interventions that should target patients with the greatest needs and promote frequent contacts with the healthcare team. The selection and training of the case manager was also an important factor to foster patient engagement in CM. Coordination of care, self-management support and assistance with care navigation were key CM activities. The main issues reported by unsuccessful CM interventions were problems with case finding or lack of care integration. Conclusions : CM interventions for frequent users of healthcare services should ensure adequate case finding processes, rigorous selection and training of the case manager, sufficient intensity of the intervention, as well as good care integration among all partners. Other studies could further evaluate the influence of contextual factors on intervention impacts

The experience of pregnant women in contexts of vulnerability of prenatal primary nursing care: a descriptive interpretative qualitative study

Background Prenatal primary nursing care contributes to improving the health outcomes of mothers and unborn babies. Some pregnant women in contexts of vulnerability experience prenatal nursing care in a positive way, while some do not. A better understanding of factors influencing this experience could help improve prenatal nursing care. The aim of this study was to describe factors influencing the prenatal primary nursing care experience of pregnant women in contexts of vulnerability. Methods Thorne’s qualitative interpretative descriptive approach was used. Twenty-four pregnant women in contexts of vulnerability were recruited in local community service centers in Quebec, Canada, using purposive and snowball samplings, to carry out a semi-structured interview. Participants were 16 years old and over, in their second or third trimester, or had given birth in the previous year, and received prenatal nursing care through community health services. Data collection methods included a logbook, sociodemographic questionnaire and semi-structured interview on vulnerable pregnant women’s experience with prenatal primary nursing care. The Qualitative Analysis Guide of Leuven guided the inductive thematic analysis, following a constant comparative iterative process. Results The women’s experience was initially influenced by the fulfillment of their needs and expectations. These stem from their previous or current pregnancy experiences, their motivation to receive prenatal care, their family concerns as well as their contexts of vulnerability. From the pregnant women’s perspective, the main factors that influenced their experience were the nurse’s approach, characteristics and interventions that all impact on their relationship with nurses, as well as the prenatal primary care organization, including the modalities of prenatal care (i.e. schedule, setting, duration, number and frequency of meetings), the continuity and the program’s prenatal care services, such as referral to a nutritionist, social worker or other services. Conclusions A conceptual framework is proposed to describe relationships among the factors distributed in three dimensions that influence the experience of pregnant women in contexts of vulnerability and to guide nurses in the improvement of prenatal primary care. Considering the complexity of this experience, a person-centered approach is mandatory to promote a positive experience, equity and a better use of services

Factors associated with frequent use of emergency-department services in a geriatric population: a systematic review

Background Frequent geriatric users of emergency departments (EDs) constitute a small group of individuals accounting for a disproportionately high number of ED visits. In addition to overcrowding, this situation might result in a less appropriate response to health needs and negative health impacts. Geriatric patients turn to EDs for a variety of reasons. A better understanding of the variables associated with frequent ED use will help implement interventions best suited for their needs. Objective This review aimed at identifying variables associated with frequent ED use by older adults. Methods For this systematic review, we searched Medline, CINAHL, Healthstar, and PsyINFO (before June 2018). Articles written in English or French meeting these criteria were included: targeting a population aged 65 years or older, reporting on frequent ED use, using an observational study design and multivariate regression analysis. The search was supplemented by manually examining the reference lists of relevant studies. Independent reviewers identified articles for inclusion, extracted data, and assessed quality with the JBI Critical Appraisal Checklist for Studies Reporting Prevalence. A narrative synthesis was done to combine the study results. A sensitivity analysis was performed to evaluate the effect of removing the studies not meeting the quality criteria. Results Out of 5096 references, 8 met our inclusion criteria. A high number of past hospital and ED admissions, living in a rural area adjacent to an urban center, low income, a high number of prescribed drugs, and a history of heart disease were associated with frequent ED use among older adults. In addition, having a principal-care physician and living in a remote rural area were associated with fewer ED visits. Some variables recognized in the literature as influencing ED use among older adults received scant consideration, such as comorbidity, dementia, and considerations related to primary-care and community settings. Conclusion Further studies should bridge the gap in understanding and give a more global portrait by adding important personal variables such as dementia, organizational variables such as use of community and primary care, and contextual variables such as social and economic frailty