Because of their high prevalence and significant effects, chronic diseases (CD) pose a major challenge for health care and social services, for society and for the persons affected . These individuals often have to make important day-to-day adjustments as a result of disability, loss of income, and a declining quality of life [2, 3]. It is now recognized that primary care should be central to the customized and effective management of CD [4, 5], and that innovative strategies targeting the current organization of primary care must be offered and evaluated to better support the individuals affected , particularly the most vulnerable . To meet the complex needs of people with CD and to reduce societal consequences, primary care must provide a range of services that are interdisciplinary, person-centred and adjusted to the individual’s current health conditions and characteristics [7, 8]. These services must also be oriented towards self-management, where the people affected and their families are called upon to play a greater role in the management of their health [1, 7, 9].
A number people with CD require higher intensity care because of personal characteristics that increase their vulnerability. This applies especially to the socioeconomically disadvantaged [10, 11] and to those who present a comorbid mental health condition [12, 13] or multimorbidity (two or more CD) [13, 14]. In addition to a compromised quality of life and an increased risk of social isolation, these individuals have problems complying with treatment, adopting healthy behaviours and managing their health. This can result in increased services use, like emergency department visits and hospitalizations [15, 16]. Case management strategies could be developed to address the vulnerability factors of frequent users in order to prevent inequities in health care and related costs .
In 2004, Family Medicine Groups (FMG) were implemented by the ministère de la santé et des services sociaux du Québec (Quebec’s ministry of health and social services) to improve accessibility, continuity, and coordination of health care in Quebec . A FMG is an administrative arrangement for existing practices in which primary care physicians who wish to participate are grouped together to collaborate with nurses to offer primary care services, including patient follow-up, health promotion and preventive care, to a group of registered patients. It offers access to care 10 hours a day, seven days a week, through regular appointments, walk-in clinics, home visits, and after-hours health coverage using telephone hot-lines and emergency on-call services. Family physicians who are members of FMG will also work closely with other health care professionals in community services centres, hospitals, community pharmacies, etc., to complement the services they offer . Since the creation of these new care teams, FMG nurses have already improved health education and the accessibility and continuity of services for certain patients, including those with diabetes, hypertension, on anticoagulant treatment, etc. . However, the most vulnerable groups still pose major challenges in terms of accessibility, delivery and coordination of primary care . The current work organization in FMG cannot optimally respond to the multiple requests, the considerable needs for self-management support of these patient groups, and their frequent need to access various health care resources , due, among other things, to lack of coordination and integration of services.
A major consultation process conducted in 2010 on the organization of CD services in the Saguenay-Lac-Saint-Jean (SLSJ) region of Québec, identified two potential solutions to meet the challenges posed by vulnerable patients with CD who frequently use hospital services : (1) Improve the coordination of services through case management; and (2) Develop strategies to support self-management. Some vulnerable patients could benefit from closer monitoring by a case management nurse [1, 23] within a primary care team linked to other network resources [1, 6], and from self-management support [2, 6]. Case management programs for frequent users of emergency departments have already been developed or are being developed in the six Centre de santé et de services sociaux (CSSS) (health and social services centres) of the SLSJ region, including the two CSSS participating in the project. Without being formally evaluated, an assessment of their programs has brought to light several positive points : a significant decrease in the number of frequent users of emergency services; a high level of satisfaction among users and stakeholders; and close cooperation between the program coordinator and FMG nurses, who are considered essential partners for patients with CD. Although promising, these case management programs are often limited to the most serious cases due to capacity issues (50 persons per year at the CSSS de Chicoutimi).
Faced with the growing needs and primary care challenges posed by increasingly vulnerable patients, the Agence de santé et de services sociaux of the SLSJ region (regional health and social services agency) and the two partner CSSS proposed to implement similar and complementary primary care interventions to allow vulnerable patients with CD to benefit from case management by a nurse within their FMG. The expansion of case management within FMG will allow, together with the case management services already offered by the CSSS, a better response to the complex needs of vulnerable patients, as well as improved services integration. Case management will be performed in the primary care setting, the FMG, ensuring a better collaboration between case management nurse and family doctor . The presence of a primary contact (FMG nurse), who is a generalist and accessible, will promote the coordination of patient care. As a result, the provision of case management can be adjusted in intensity and duration based on patient needs, ensuring continuity and long-term management.
The proposed intervention seeks to address many of the challenges posed by CD, based on scientific evidence. First, case management by primary care nurses has proven to be effective for various CD [25–27]. In fact, a key element of the effectiveness of an interdisciplinary approach to CD for vulnerable primary care patients is the use of a single caregiver (usually a nurse) to serve as the main contact and to coordinate interventions between health care professionals and the services provided . However, most studies on this issue have been conducted in the context of a specific CD, which does not correspond to the reality of the clientele currently managed in primary care. Moreover, the implementation of strategies for interdisciplinary patient follow-up in the management of CD has to be evaluated in its context.
To date, strategies to support self-management remain poorly implemented in FMG. However, the positive effects of self-management support groups, such as the Stanford Chronic Disease Self-Management Program, are widely recognized [29, 30]. These strategies are intended mostly for people who are in an early stage of their disease . A recent study in primary care conducted in Ontario (Canada) showed a reduction in hospital length of stay and an increase in patient satisfaction with this type of self-management program . Another study, in which vulnerable CD patients in primary care were evaluated after a six-week intervention to support self-management, showed positive effects with regard to patient self-management capacity, but there was no comparison with a control group . Very few studies have examined the implementation mechanisms and the involvement of primary care professionals in such self-management support programs . The introduction of a self-management group support program in FMG may inpsire more vulnerable people to participate and attain positive outcomes .
This project aims to document the implementation and effects, within four FMG of the SLSJ region (Quebec, Canada), of a pragmatic intervention involving case management by a nurse to promote interdisciplinary person-centred follow-up and group self-management support for frequent users of hospital services (emergency department visits and hospitalizations) with CD (diabetes, cardiovascular diseases, respiratory diseases, musculoskeletal diseases and/or chronic pain). The evaluation of the intervention has three objectives: (1) to analyze the implementation of the intervention within the existing structures of the four participating FMG in order to: (a) Explain how the various contexts have influenced the implementation of the intervention and the observed effects, and (b) Identify elements that can be assessed and applied in order to improve the intervention and to promote its implementation in other FMG; (2) to evaluate the proximal (self-efficacy, self-management practices, health habits, activation and psychological distress) and intermediate (empowerment, quality of life and health care use) effects of this intervention among patients; (3) Conduct an economic analysis of the cost-effectiveness and cost-benefit of the intervention.
The theoretical framework of the intervention is based on two conceptual models. One supports the methodology of the clinical intervention, and the other supports the implementation process, change management, and knowledge transfer.
The first model is that of the UK National Health Service on innovation in health care and social services for people with CD . This model incorporates the basic principles of the Chronic Care Model , while also drawing on lessons learned from US models, such as that of Kaiser Permanente, with regard to the intensity of care that is appropriate for the complex needs of patients , and of the Evercare model, with regard to the use of case management nurses in primary care . The goal is to improve the health and quality of life of people with CD by providing personalized and ongoing support, based on the best evidence in the field. This model proposes the implementation of a case management system for patients with complex needs by making primary care a central part of the organization of services. To achieve this, the model suggests a structured approach that will allow for interaction between CSSS partners and community resources in order to provide integrated services. It also proposes the implementation of self-management support practices.
The second model the Promoting Action on Research Implementation in Health Services (PARiHS) [38, 39]. According to this model, successful implementation depends on the nature and type of evidence from previous studies, the results of the proposed study, the context in which it is introduced, and how the process is facilitated. The value of the evidence depends not only on its scientific reliability, but also on the experience of the professionals and partners, as well as on patient preferences. The implementation of evidence into practice is achieved through a dialogue with knowledge users and must take their views into consideration. Some settings are more amenable to implementation than others, particularly where there are natural leaders. Finally, this model emphasizes the importance of appropriate facilitation, including various strategies for managing change and increasing the chances of a successful implementation.