La prise en charge des patients souffrant d’une maladie chronique : dynamiques de mise en œuvre d’un modèle de soins

Les maladies chroniques regroupent un ensemble de problèmes de santé tels que le diabète, l’hypertension, les maladies pulmonaires obstructives chroniques (MPOC) et le cancer. Elles requièrent une prise en charge continue, durant plusieurs années et évoluent généralement lentement. Ce projet de recherche vise à comprendre et à analyser les dynamiques associées à la mise en place d’un modèle organisationnel qui permet une meilleure prise en charge des patients atteints de maladies chroniques et à porter une attention particulière aux mécanismes professionnels et organisationnels qui favorisent la mise en place de ce modèle de soin dans un contexte pluraliste des organisations et du système de santé. Il vise aussi à explorer si le modèle mis en place permet d’atteindre les objectifs et les résultats de soins escomptés par le modèle. Le contexte de notre étude s’inscrit dans le réseau de l’écosystème des maladies chroniques et des relations inter-organisationnelles lors de l’implantation et de la mise en œuvre du Centre d’accompagnement interdisciplinaire en maladies chroniques CAIMC du CSSS du Haut-Richelieu-Rouville à Saint-Jean-sur-Richelieu. Les données récoltées proviennent d’entrevues individuelles représentatives de l’ensemble des acteurs professionnels du terrain, se fondent sur des documents et rapports, notamment ceux de divers comités de travail ainsi que de protocoles de soins. Notre recherche s’appuie sur le cadre conceptuel de l’analyse stratégique de Crozier et Friedberg (1977) ainsi que sur le système des professions d’Abbott (1988). Elle met en évidence une complexité organisationnelle et structurelle qui rend difficile la gestion du changement dans les organisations pluralistes, surtout lors de l’implantation d’un modèle de soin dans un long horizon temporel. Cette implantation résulte de la gestion d’un processus d’apprentissage continu au sein de l’organisation. Le modèle que nous proposons constitue un cadre d’analyse qui permet une synthèse de diverses approches qui favorisent la compréhension de phénomènes complexes et leur gestion. Il contribue ainsi à raffiner et approfondir la compréhension des dynamiques organisationnelles et professionnelles associées à la mise en place d’un modèle organisationnel. Il peut valablement être utilisé pour l’étude de divers modèles de soins, outre celui des maladies chroniques. Il serait d’ailleurs judicieux de considérer un tel cadre d’analyse avant toute expérimentation ou implantation de modèles de soins dans des organisations pluralistes de santé. Cette étude permet de formuler des recommandations à l’attention des décideurs publics. Elle soutient, notamment, que la mobilisation d’un intrapreneur, ayant l’étoffe d’un leader transformationnel dans un cadre organisationnel agile, favoriserait la création et l’acquisition de connaissances permettant d’accélérer les processus et d’améliorer l’autogestion des patients.Chronic diseases include a range of health problems such as diabetes, hypertension, chronic obstructive pulmonary disease (COPD) and cancer. They require continuous management over several years and generally evolve slowly. On the one hand, this research project aims to understand and analyze the dynamics associated with the implementation of an organizational model that allows for better management of patients with chronic diseases. On the other hand, it sheds light on the professional and organizational mechanisms that promote this chronic care model's implementation in a pluralistic context of organizations and the health system. Finally, it explores whether the model implemented makes it possible to achieve the model's objectives and results of care. The context of our study is part of the network of the chronic disease ecosystem and inter-organizational relations during the implementation and operation of the Centre d'accompagnement interdisciplinaire en maladies chroniques CAIMC of the CSSS du Haut-Richelieu-Rouville in Saint-Jean-sur-Richelieu. The data collected came from individual interviews representative of all professional actors in the field, documents and reports, particularly those of various working committees and care protocols. Our research is based on the conceptual framework of Crozier and Friedberg's (1977) strategic analysis and Abbott's (1988) system of professions. It highlights an organizational and structural complexity that makes it difficult to manage change in pluralistic organizations, especially when implementing a chronic care model over a long period of time. Implementation results from the management of a continuous learning process within the organization. The model we propose constitutes an analytical framework that allows a synthesis of various approaches that contribute to the understanding of complex phenomena and their management. It thus helps to refine and deepen the understanding of the organizational and professional dynamics associated with the implementation of an organizational model. It could be used for the study of other care models, in addition to chronic diseases. It would be appropriate to consider the use of such an analytical framework before experimentation or implementation of care models in pluralistic health organizations. This study makes several recommendations to public decision-makers. In particular, it argues that the mobilization of an intrapreneur, with the makings of a transformational leader in an agile organizational framework, would promote the creation and acquisition of knowledge to accelerate processes and improve patient self-management

Study of materials with modified structure and adaptable photoluminescence

L'objectif principal de cette thèse était l’élaboration et l’étude de matériaux « modifiés » à photoluminescence adaptable et optimisée, en vue d’applications diversifiées, la détection de rayonnements ou l’éclairage basse consommation.Les caractérisations structurale, microstructurale et vibrationnelle des matériaux à structure modifiée ont permis d’établir des corrélations entre les propriétés photoluminescentes et trois types d’effets induisant des modifications de propriétés structurales des effets mécaniques dans le cas d’une transition piézochrome du molybdate CoMoO4, de dopage du tungstate de cobalt et de substitution chimique dans le cas de la solution solide Ce2-xSmx(WO4)3. Les déterminations structurales par diffraction de rayons X ont été systématiquement exploitées par affinement Rietveld. Les études de photoluminescence ont été faites sous excitation monochromatique UV, et sous excitation X polychromatique. Divers types de défauts structuraux seraient à l’origine des variations de photoluminescence observées pour les trois types de matériaux « modifiés » étudiés. Les diagrammes de chromaticité ont permis de traduire les variations spectrales en termes d’émissions colorées propres à chaque matériau modifié.The main objective of this thesis was the development and study of "modified" materials with adaptable and optimized photoluminescence, with a view to diverse applications, radiation detection or low-consumption lighting. The structural, microstructural and vibrational characterizations of materials with a modified structure have made it possible to establish correlations between the photoluminescent properties and three types of effects inducing modifications of structural properties: mechanical effects in the case of a piezochromic transition of CoMoO4 molybdate, doping of cobalt tungstate and chemical substitution in the case of the solid solution Ce2-xSmx (WO4)3. X-ray diffraction structural determinations have been systematically exploited by Rietveld refinement. The photoluminescence studies were carried out under monochromatic UV excitation, and under polychromatic X excitation. Various types of structural defects are believed to be the cause of the variations in photoluminescence observed for the three types of "modified" materials studied. Chromaticity diagrams made it possible to translate spectral variations in terms of color emissions specific to each modified material

Role of chemical substitution in the photoluminescence properties of cerium samarium tungstates Ce

In the general framework of the development of materials with tunable photoluminescence, a series of cerium samarium tungstates Ce(2-x)Smx(WO4)3 with x≤0.3 was synthesized by a coprecipitation method followed by thermal treatment at 1000 °C. The polycrystalline compounds were characterized by X-ray diffraction, scanning electron microscopy and photoluminescence experiments. In the present work, the objective would be to determine the role of PL emitting centers in the variations of PL intensities. Firstly, Rietveld analysis showed a decrease of cell parameters and confirmed that a solid solution was obtained. Diffraction profile analyses showed that structural distortions increasing with composition x were observed: they were ascribed to difference in cation sizes of Ce3+ and Sm3+, and to defects generated during crystal growth. The photoluminescence (PL) spectra were obtained under X-Ray (45 kV-35 mA) and UV (364.5 nm) excitations. Two PL emissions of Ce3+ were observed only under UV excitation. Four PL emissions of Sm3+ were observed under UV and X-ray excitations, and their intensities decreased with increasing composition x. Two additional transitions were observed under UV and X-ray excitations: they were attributed to oxygen vacancy defects. In the range 800 to 1000 nm, an increasing IR emission is observed: it was ascribed to emissions due to other oxygen vacancies. The main results are reported in Table 1. The chromaticity diagram (see Figure 1) showed that the colors associated with PL responses vary with Sm composition and excitation energies. This offers the opportunity to develop materials with tunable PL. To better understand this complex behavior, now, we plan to study the solid solution in the composition range x>0.3

Role of chemical substitution in the photoluminescence properties of cerium samarium tungstates Ce(2-x)Smx (WO4)3 (0≤x≤0.3)

In the general framework of the development of materials with tunable photoluminescence, a series of cerium samarium tungstates Ce(2-x)Smx(WO4)3 with x≤0.3 was synthesized by a coprecipitation method followed by thermal treatment at 1000 °C. The polycrystalline compounds were characterized by X-ray diffraction, scanning electron microscopy and photoluminescence experiments. In the present work, the objective would be to determine the role of PL emitting centers in the variations of PL intensities. Firstly, Rietveld analysis showed a decrease of cell parameters and confirmed that a solid solution was obtained. Diffraction profile analyses showed that structural distortions increasing with composition x were observed: they were ascribed to difference in cation sizes of Ce3+ and Sm3+, and to defects generated during crystal growth. The photoluminescence (PL) spectra were obtained under X-Ray (45 kV-35 mA) and UV (364.5 nm) excitations. Two PL emissions of Ce3+ were observed only under UV excitation. Four PL emissions of Sm3+ were observed under UV and X-ray excitations, and their intensities decreased with increasing composition x. Two additional transitions were observed under UV and X-ray excitations: they were attributed to oxygen vacancy defects. In the range 800 to 1000 nm, an increasing IR emission is observed: it was ascribed to emissions due to other oxygen vacancies. The main results are reported in Table 1. The chromaticity diagram (see Figure 1) showed that the colors associated with PL responses vary with Sm composition and excitation energies. This offers the opportunity to develop materials with tunable PL. To better understand this complex behavior, now, we plan to study the solid solution in the composition range x>0.3

Role of Chemical Substitution in the Photoluminescence Properties of Cerium Samarium Tungstates Ce (2– x ) Sm ₓ (WO₄)₃ (0 ≤ x ≤ 0.3)

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