Editors Raynald Pineault Pierre Tousignant

Transcription

1 Editors Raynald Pineault Pierre Tousignant

2 A publication of the Direction de la santé publique Régie régionale de la santé et des services sociaux de Montréal-Centre 1301, Sherbrooke Est Montréal, (Québec) H2L 1M3 Téléphone : (514) Graphic design: David Young Linda Daneau Photography: Jean Bruneau Direction de la santé publique Régie régionale de la santé et des services sociaux de Montréal-Centre (2000) Legal Deposit: 1 st quarter 2001 Bibliothèque nationale du Québec National Library of Canada ISBN:

3 Foreword This research collective is part of the Public Health Department's strategy to link up milieus devoted to research with those involved in practice. Findings from the investigations presented will be used in two ways: first to back up the contents of the 2000 Annual Report on the health of Montrealers, then to prepare one of the four cases described in the interdisciplinary seminar on The Reform of Canada's Health Care System and Its Impact on Public Health, which was held in Montreal on 16 and 17 November This collective is a newly-minted and effective means of transferring research findings to the milieus involved in practice. It opens the way to closer collaboration between researchers and decision-makers. The Public Health Department supports this sort of initiative and encourages its development. Public Health Director Richard Lessard Research Collective iii

4 TABLE OF CONTENTS List of collaborators vi Introduction 1 Chapter 1: List of projects and researchers 3 Chapter 2: Methods 6 Chapter 3: Transformations in Montreal 8 Chapter 4: Synthesis 11 Research protocols 12 Funding bodies 12 Measures targeted by the projects 13 Findings Implementation of the reform 14 Accessibility 14 Community-based care after discharge from hospital 14 Creation of integrated services networks 15 Hospital-centredness 16 Hospital-CLSC overlap 16 Erosion of prevention and promotion mission in CLSCs 16 Evidence of effective measures 16 Health effects 17 Chapter 5: Conclusion 18 Chapter 6: Synopses of research projects Effects of the health services reorganization on emergency department overcrowding Transfer of dependent clients from CRPDIs to the Verdun Champlain-Manoir 27 CHSLD (Centre hospitalier de soins longue durée: long-term-care hospital) 3. Evaluation of the impact made on accessibility by the reconfiguration of Montreal-Centre s network of health services 29 iv Research Collective

5 4. Implementation and operational assessment: coordinating CHSCDs- CLSCs- attending physicians; post-hospital care and administration User friendliness and organizational framework of home technologies CLSC promotion and prevention (PP) services in the field of perinatalitychildhood-youth: Profile and study of determinants Impact of health system's reconfiguration on the organization of preventive services offered by CLSCs in the Montreal-Centre region Evaluation of the impact of postnatal follow-up procedures on mother and newborn in the context of early obstetric discharge Strategic analysis of the implementation of a network of perinatal care Diabetes project: Evaluation of the implementation of an integrated-services model for patients suffering from diabetes in the Côte-des-Neiges district Cost-effectiveness of early supported discharge for stroke Procedures and perceived quality of care for the elderly in emergency departments: Impact on risk of return visit Randomized study evaluating the effect of an inter-disciplinary program of ambulatory clinical follow-up on the rate of rehospitalization, quality of life, and use of hospital resources among patients with heart failure Evaluation of the effectiveness of the network of services offered to persons with mental problems who live in the community Impact of day surgery on users and their families Impact of reduced hospital stay on users and their families Evaluation of the SIPA (système de services intégrés pour les personnes âgées en perte d'autonomie: system of integrated services for dependent seniors) demonstration project, per capita simulation 87 Appendix: List of measures in the transformation plan of the 93 Régie régionale de la santé et des services sociaux de Montréal-Centre Research Collective v

6 List of collaborators Denis Allard Sylvie Cardin Danielle D'Amour Odette Doyon Lise Goulet Mylène Kosseim Danielle Larouche Normand Lauzon Paule Lebel Pascale Lehoux Richard Lessard Nancy Mayo Léo-Roch Poirier Lucie Richard Danièle Roberge Denis Roy Public Health Department, Régie régionale de la santé et des services sociaux de Montréal-Centre Unité de recherche évaluative, Centre de recherche, Centre hospitalier de l Université de Montréal Faculté des sciences infirmières, Université de Montréal Université du Québec à Trois-Rivières and Université de Montréal Département de médecine sociale et préventive, Université de Montréal Public Health Department, Régie régionale de la santé et des services sociaux de Montréal-Centret Unité de recherche évaluative, Centre de recherche, Centre hospitalier de l Université de Montréal Evaluation and Studies Department, Régie régionale de la santé et des services sociaux de Montréal-Centre Public Health Department, Régie régionale de la santé et des services sociaux de Montréal-Centre and Université de Montréal Département de l Administration de la santé, Université de Montréal Public Health Department, Régie régionale de la santé et des services sociaux de Montréal-Centre Joint Departments of Epidemiology and Biostatistics and of Occupational Health, McGill University Public Health Department, Régie régionale de la santé et des services sociaux de Montréal-Centre Faculté des sciences infirmières, Université de Montréal Unité de recherche évaluative, Centre de recherche, Centre hospitalier de l Université de Montréal Public Health Department, Régie régionale de la santé et des services sociaux de Montréal-Centre vi Research Collective

7 Introduction The combined challenge of the availability of new technologies and new means of communication and the crisis in public finances has led the State to revisit the organization of its network of health services, which has resulted in the reconfiguration of this network in Montreal-Centre. This has meant a redefinition and reorganization of social and health services implying the reassignment of human, material, and financial resources in all the region s health establishments (hospitals, CLSCs, etc.) and a reduction of the budgets devoted to health services. The reconfiguration arose from the implementation of measures defined in the plan drawn up by the Régie régionale de la santé et des services sociaux (RRSSS: hereafter cited in this document simply as the Régie or the Régie régionale) 1. These measures cover fields related to physical and mental health, social adaptation, prevention of illness, and health promotion. Begun in April 1995, implementation of the transformation planned is now completed. To ensure follow-up on the impact of the measures implemented, the Régie oversees the evaluation of its regional network. Three components of the transformation have thus been chosen for evaluation: user satisfaction, achievement of the objectives of the reconfiguration, and their impact on the health and well-being of the population. The last component falls under the mandate of the Public Health Department. An earlier document 2 describes the process involved in defining the research program; presents the theoretical framework behind that process; identifies the indicators chosen; and shows how they relate to the theoretical framework and the potential effects of the reconfiguration as identified by health professionals. This document also contains the technical indicator sheets used in monitoring and the projects carried out to achieve the program s goals. The first report on monitoring results has just been published 3. The present document summarizes the findings that a group of researchers from various milieus agreed to pool as members of a research collective. The goal is to bring together the results of several research projects which have examined the transformation plan's impact on the health of Montrealers, so as to provide the designers of that plan with the best possible feedback. The information presented here is only that currently available; several projects are still in progress. This research collective aims to pinpoint as precisely as possible the impact of the transformation on Montreal s health system and to provide decision-makers with the information needed for a clear-eyed view of these transformations and their future. The first chapter of this document enumerates the research projects on which the information is based and the researchers who agreed to join the collective. The second presents the methods used 1 Achieving a New Balance (1995), document produced by the Régie régionale de Montreal-Centre fully detailing the measures adopted to respond to the demands of the ministère de la Santé et des Services sociaux with regard to the efficiency of its system. 2 Dupont, M.A., G. Lavoie, LR Poirier, P. Tousignant. Démarche de planification et identification des descripteurs du monitorage en santé physique. Direction de la santé publique. Régie régionale de la santé et des services sociaux de Montréal-Centre, 2 e édition, mars Tousignant, P., G. Lavoie, L.-R. Poirier, D. Lamontagne, D. roy, M.A. Dupont. Évaluation de la reconfiguration du réseau sur la santé et le bien-être de la population du Montréal-Centre - Résultats du monitorage. Direction de la santé publique de Montréal-Centre, octobre Research Collective 1

8 to produce the synthesis. The third describes the main structural changes characterizing the transformations carried out in Montreal. This description contextualizes the observations drawn in the synthesis. In the fourth chapter, we synthesize the findings and interpret them in accordance with the research perspective adopted. Finally, in the fifth chapter, we conclude by stating what our interpretation implies for the network's decision-makers and what avenues of research should be pursued to gain better insight into the effects of the reconfiguration. 2 Research Collective

9 CHAPTER 1 List of Projects and Researchers Research Collective 3

10 Listed below are the 17 research projects on health services offered in Montreal which are connected to one or more of the measures appearing in the Montreal-Centre Régie s transformation plan (please see appendix). The researchers who agreed to join the collective are also identified. Synopses of the projects listed are provided in chapter EFFECTS OF THE HEALTH SERVICES REORGANISATION ON EMERGENCY DEPARTMENT OVERCROWDING Danièle Roberge 4, Raynald Pineault 4, Pierre Tousignant 5,6, Sylvie Cardin 4, Danielle Larouche 4 TRANSFER OF DEPENDENT CLIENTS FROM CRPDIS TO THE VERDUN CHAMPLAIN MANOIR CHSLD Militza Zencovich 8 EVALUATION OF THE IMPACT MADE ON ACCESSIBILITY BY THE RECONFIGURATION OF MONTREAL-CENTRE'S NETWORK OF HEALTH SERVICES Raynald Pineault 7, Léo-Roch Poirier 5, Ronald Lebeau, Véronic Ouellette IMPLEMENTATION AND OPERATIONAL ASSESSMENT: COORDINATING CHSCDS-CLSCS- ATTENDING PHYSICIAN; POST-HOSPITAL CARE/ADMINISTRATIVE LEVEL Carole Lécuyer 8 USER FRIENDLINESS AND ORGANIZATIONAL FRAMEWORK OF HOME TECHNOLOGIES Pascale Lehoux 9, Raynald Pineault 7, Lucie Richard 10, Jocelyne St-Arnaud, Henk Rosendal CLSC PROMOTION AND PREVENTION (PP) SERVICES IN THE FIELD OF PERINATALITY-CHILDHOOD-YOUTH: PROFILE AND STUDY OF DETERMINANTS Lucie Richard 10, Danielle D'Amour 10, Jean-Marc Brodeur 7, Raynald Pineault 7, Louise Séguin 7, Jean-François Labadie, Robert Latour IMPACT OF HEALTH SYSTEM'S RECONFIGURATION ON THE ORGANIZATION OF PREVENTIVE SERVICES OFFERED BY CLSCS IN THE MONTREAL-CENTRE REGION Léo-Roch Poirier 5,6, Patricia Goggin 5, Natalie Kishchuk EVALUATION OF THE IMPACT OF POSTNATAL FOLLOW-UP PROCEDURES ON MOTHER AND NEWBORN IN THE CONTEXT OF EARLY OBSTETRIC DISCHARGE Lise Goulet 7, Danielle D'Amour 10, Raynald Pineault 7, Louise Séguin 7, Jocelyn Bisson 4 Unité de recherche évaluative, Centre de recherche, Centre hospitalier de l Université de Montréal. 5 Public Health Department, Régie régionale de la santé et des services sociaux de Montréal-Centre. 6 Institut national de santé publique du Québec. 7 Département de médecine sociale et préventive, Université de Montréal. 8 Studies and Evaluation Department, Régie régionale de la santé et des services sociaux de Montréal-Centre. 9 Département de l'administratin de la santé, Université de Montréal. 10 Faculté des sciences infirmières, Université de Montréal. 11 Joint Departments of Epidemiology and Biostatistics and of Occupational Health, McGill University. 12 Department of Medicine, McGill University. 13 Hôpital Douglas. 4 Research Collective

11 19 STRATEGIC ANALYSIS OF THE IMPLEMENTATION OF A NETWORK OF PERINATAL CARE Danielle D'Amour 10, Lise Goulet 7, Raynald Pineault 7, Karina Daigle. DIABETES PROJECT: EVALUATION OF THE IMPLEMENTATION OF AN INTEGRATED-SERVICES 10 MODEL FOR PATIENTS SUFFERING FROM DIABETES IN THE CÔTE-DES-NEIGES DISTRICT André-Pierre Contandriopoulos, Danielle Larouche 4, Rosario Rodriguez 9, Raynald Pineault COST-EFFECTIVENESS OF EARLY DISCHARGE FOR STROKE Nancy Mayo 11, Josephine Teng, Sharon Wood-Dauphinee 11, Robert Côté 12, Eric Latimer 13, James Hanley 11 PROCEDURES AND PERCEIVED QUALITY OF CARE FOR THE ELDERLY IN EMERGENCY DEPARTMENTS: IMPACT ON RISK OF RETURN VISIT Sylvie Cardin 4, Raynald Pineault 7, Danièle Roberge 4, Eddy Lang, Michel Tétrauft, Josée Verdon 14 RANDOMIZED STUDY EVALUATING THE EFFECT OF AN INTERDISCIPLINARY PROGRAM OF AMBULATORY CLINICAL FOLLOW-UP ON THE RATE OF REHOSPITALIZATION, QUALITY OF LIFE, AND USE OF HOSPITAL RESOURCES AMONG PATIENTS WITH HEART FAILURE O. Doyon 15, J. Brophy 16, J.-L. Rouleau 17, A. Ducharme 18, F. Gauthier 18, M. Langlois 18, J. Loyer 18, S. Heppel 18 EVALUATION OF THE EFFECTIVENESS OF THE NETWORK OF SERVICES OFFERED TO PERSONS WITH MENTAL PROBLEMS WHO LIVE IN THE COMMUNITY Léo-Roch Poirier 5, Louise Fournier 5, Deena White 19, Céline Mercier 20, Alain Lesage 21 IMPACT OF DAY SURGERY ON USERS AND THEIR FAMILIES Pierre Tousignant 5,6, Lee Soderstrom 22, Jean-Pierre Lavoie 5, Terry Kaufman 23 IMPACT OF REDUCED HOSPITAL STAY ON USERS AND THEIR FAMILIES Pierre Tousignant 5,6, Lee Soderstrom 22, Jean-Pierre Lavoie 5, Terry Kaufman 23 EVALUATION OF THE SIPA (SYSTÈME DE SERVICES INTÉGRÉS POUR LES PERSONNES ÂGÉES EN PERTE D'AUTONOMIE: SYSTEM OF INTEGRATED SERVICES FOR DEPENDENT SENIORS) DEMONSTRATION PROJECT, PER CAPITA SIMULATION François Béland 9, Howard Bergman 16, Paule Lebel 17, André-Pierre Contandriopoulos 9, Jean-Louis Denis 9, Pierre Tousignant 5,6, Joanne Monette, Francine Ducharme, Anne Langley 14 Centre Hospitalier Universitaire de Montréal 15 Université du Québec à Trois-Rivières/Université de Montréal. 16 McGill University. 17 Université de Montréal. 18 Institut de cardiologie de Montréal. 19 Département de sociologie, Université de Montréal 20 Division de la recherche psychosociale, Centre de recherche de l'hôpital Douglas 21 Centre de recherche Fernand-Seguin, Hôpital Louis-H.-Lafontaine 22 Department of Economics, McGill University. 23 Notre-Dame-de-Grâce CLSC. Research Collective 5

12 CHAPTER 2 Methods 6 Research Collective

13 To gather the primary-resource information needed for the synthesis in chapter 4, we first determined which of the research projects on health services were potentially linked to at least one of the measures stated in the Régie's transformation plan. At a meeting of all the main researchers engaged in these projects held on 29 June 2000, we explained the objectives of the research collective and agreed upon a synopsis model that the researchers would use to send us crucial information concerning their project. The information would describe results available as of the deadline set for 6 September The synopsis model adopted called for descriptive elements such as the project s objectives and protocol, but was more specifically focused on evidence-based findings and their usefulness in planning and decision-making. Once all the synopses had been collected and analyzed, we held a one-day session where all the researchers presented their projects and answered questions from other participants (see the list of collaborators). To wrap up the day's session, an oral overview was proposed for discussion by all the participants. Following the meeting, researchers were encouraged to review the synopses submitted in light of the information and ideas exchanged during the session and to make any modifications they judged appropriate. The editors of this document then prepared a written synthesis of the information contained in the synopses and that gathered during the one-day presentation/discussion session. Finally, the written synthesis was submitted for approval to the jprojects principal researchers. The final version of chapter 4 takes into account their suggestions and modifications. Research Collective 7

14 CHAPTER 3 Transformations carried out in Montreal 8 Research Collective

15 The list of measures designed to transform the Montreal network is a long one indeed. It is presented in the appendix in its entirety to help the reader understand the research synopses presented in chapter 6. One section of the synopsis is specifically labeled Link with the reconfiguration/reform of health care. In this section, researchers cite the numbers of the measures with which their research project shows some link. In our effort to describe just how far-reaching the transformation of the Montreal network has been, we made no attempt to measure the degree to which all the measures appearing on the list have been implemented. Since these measures are not all of equal importance, we felt justified in singling out some of them for special attention. We have also described how the Montreal- Centre Régie s implementation plan and its effects have both been influenced by unforeseen events. There was, to mention only one, the sudden drop in the network's available human resources in the summer of 1997 caused by the early retirement program. Here is a summary of the observations which are described in detail in the document presenting the monitoring results. Each of the transformation plan's measures singled out by us appears in a shaded area, followed by the information relevant to its application. Reducing the number of beds in short-term-care hospitals One of the most important measures involved the closing of eight short-term-care hospitals and a change in the mission of a ninth hospital. This move made it possible to reduce the number of beds, thus freeing up the budgets for the proposed switch to ambulatory care and its promised reductions in health-care expenditures. All these closings and the one change in mission took place as scheduled (between November 1995 and April 1997). Between 1995 and 1998, the budget for short-term-care hospitals dropped 16% and the number of beds slid 28% (from 8505 to 6062 beds, a decrease of 2443 beds). Half of these reductions were foreseen in the transformation plan and the other half resulted from additional budget cuts. Achieving full potential in cases handled by day surgery and day hospitalization To avoid the value judgement inherent in the concept of potential, we documented the reconfiguration by using the concept of the substitution of hospital procedures by daysurgery procedures. In a subgroup of surgical interventions identified by health professionals as suitable for day surgery (which, in , offered a potentially large pool of cases for substitution), the percentage actually performed in day surgery rose from 47% to 73% between and For the remainder of surgeries requiring use of an operating room, the percentage handled in day surgery went from 18% to 29% between and These results suggest a significant level of substitution. However, we must not lose sight of the fact that, during the same period, there was a drop ( to ) in the total number of all surgeries requiring the use of an operating room. Research Collective 9

16 Reducing the average stay of patients occupying short-term beds The Régie has set a 6.8 day objective as the average hospital stay for patients in CHSGs (Centre hospitalier de soins généraux: acute care hospital) to receive short-term physical care (thus excluding psychiatric care). The average stay has constantly declined, going from 8.6 days in to 7.8 days in Other measures stated in the transformation plan A $21.4 M increase in the budget allocated to home care for the elderly. A $1.1 M allocation to community organizations. An increase of 2108 beds in facilities for a clientele requiring 2.5 hours and more of care a day. An increase of 350 beds in nursing homes for the elderly. Implementation of a one-stop service for the placement of seniors. Voluntary early retirement program On top of the modifications foreseen in the plan and the added reductions during the same period, the network's structures had to withstand another source of disruption: the voluntary early retirement program. Aimed at personnel over 50 across the entire civil service, this government program offered those with permanent positions attractive early retirement packages. A similar program was also offered to doctors belonging to the medical federations. The reduction targets initially set by the State and unions were largely exceeded. For example, 1176 of the 2801 nurses over 50 working in Montreal establishments at the start of opted for the early retirement package: almost twice as many as the 674 initially expected. The same trend was observed for all professional and technical personnel, so that in a few months between 5 % and 10 % of those with permanent positions left their jobs: a total of 5734 people. Added to all this there was about a 4% global drop in the number of doctors between 1993 and And this drop was particularly dramatic in the specialties destined to play a big role in day surgeries and thus in the switch to ambulatory care (anatomical-pathology, 8.4%; anesthesiaresuscitation, 7.9%; general surgery, 15.1%, obstetrics-gynecology, 11.7 %). 10 Research Collective

17 CHAPTER 4 Synthesis Research Collective 11

18 This chapter is a synthesis of the seventeen projects presented in chapter 6. Research protocols PROTOCOLS USED IN THE PROJECTS Protocols Number Case studies 3 Case studies and cross-sectional survey 2 Cross-sectional survey 3 Longitudinal (retro or prospective) 6 Randomized trial 3 Total 17 Each of the protocols has its strengths and weaknesses. The longitudinal studies are better designed to account for the changes which, in time, follow in the wake of the reform. Case studies have greater explanatory potential, especially with regard to the process of implementation. Crosssectional surveys are good tools for collecting detailed information based on samples and then inferring the results to the population at large. Finally, randomized trials produce the strongest evidence for research aimed at evaluating practices and treatments. The results cited here must thus be viewed with the greatest caution, especially since some of the research is still underway. However, when certain observations emerge from a convergence of results from several studies, they can justifiably be considered more reliable. Funding Organizations FUNDING FOR PROJECTS Organizations Number Montreal-Centre Régie 9 FRSQ 4 Hospitals 3 FASS 3 CIHR, NHRDP, CHSRF 9 Ministère de la Santé et des Services sociaux 5 Others 4 12 Research Collective

19 Measures targeted by the projects Measures Number of the project linked to the measure Physical Health To increase post-hospital services in CLSCs To complete implementation of Info-Health To ensure availability of first-line medical services with and without appointment To implement an interactive network in Eastend Montreal 9 10 To improve the equity and facility of access to basic services in CLSCs To monitor the objectives linked to CLSC follow-up indicators Closing of short-term-care hospitals PFT-Major ambulatory care centre To increase one-day care To reduce the average stay in hospital (DMS) To maintain capacity to perform operations To maintain capacity to provide emergency services Accessibility and efficiency of laboratory services To manage archives of short-term-care hospitals slated for closing The Elderly To increase home-care services ($21.4M) To make 24/7 nursing services available to all persons registered at a day centre or day hospital To increase home-care and community-based services (day centre) One-stop management of cases 17 Physical and intellectual disability 2 Mental health continuum 14 Youth continuum Prevention-Promotion continuum Implementation of Prevention-Promotion continuum 6 7 Infant health 6 Integrated Prevention-Promotion youth program 6 User satisfaction 12 Research Collective 13

20 Results The synthesis presented here is the product of a cross-sectional analysis of the projects mentioned above. It attempts to highlight the salient themes of our analysis. Implementation of the reform On the whole, the reform was more concerned with reducing resources than with reorganizing services. It has required major efforts on the part of hospitals to implement the measures demanded (see project no. 1 in chapter 6, p. 22). Significant progress has been made in reducing the length of stay in hospital and in increasing the use of day surgery. The effects of these changes vary from hospital to hospital and tend to show greater impact in hospitals that were already somewhat behind the trend. It is also difficult to put an exact date on the reform s starting point, since some hospitals had, so to speak, beat the reform to the draw. The hospitals in this group also stalled more quickly in reaching the reform's targets than those which had been lagging behind. Indicators thus show a slowdown in the progress of their evolution toward targets set in such areas as length of stay in hospital. Cuts in the number of hospital beds combined with shortened stays and, probably, with more seriously ill patients have drastically reduced the availability of beds and left hospitals with very little room to manoeuvre. Accessibility Between 1996 and 1998, accessibility seems to have dropped across the board, at least in the public's perception (no. 3 p. 29). It is interesting to note the role the media have to play in this perception. Users of the services have a more positive perception of their accessibility than non-users whose opinion is largely shaped by information from the media. Among the participants in the survey, we also note an increased use of emergency rooms, which runs counter to the results expected. Utilization of services has increased generally except for dependent and low-income people who have reduced their utilization of services provided by hospitals and specialists. Utilization of CLSC services has increased although the level of utilization remains small; the increase could be attributed in large part to specimen collection services for laboratory testing (no. 3 p. 29). Community-based care after discharge from hospital Several projects observed deficiencies in the system of community-based care, especially as concerns patients using home technologies, elderly patients discharged from emergency, women having just given birth, and mental-health patients (no. 5, p. 35; no 8, p. 49; no. 10, p. 60; no. 12, p. 67; no. 14, p. 75). With regard to home technologies, CLSCs seem to be having a particularly hard time handling technologies related to parentaeral nutrition and dialysis (no. 5, p. 35). The degree to which these technologies have been integrated varies widely from one CLSC to the next and, among the factors explaining this situation, we note the resistance of hospitals and the lack of effective information systems ( no. 5, p. 35). As concerns elderly patients discharged from emergency, 37% say they have no family doctor to contact in case of need. 14 Research Collective

21 Obtaining information or being referred to a CLSC lowers the risk of a return visit to emergency (no. 12, p. 67). In the area of postpartum follow-up, we are primarily struck by the wide variation in length of stay from hospital to hospital (no. 8, p. 49). As a rule, there is good follow-up. The vast majority of mothers receive a telephone call from a nurse from the hospital or the CLSC. However, we note a surprising duplication in services at a time when resources are so scarce. Indeed, 51% of mothers receive calls from both the hospital and the CLSC (no. 8, p. 49). These deficiencies in community-based care seem to have their consequences. We thus observe that 15% of the elderly return to emergency two weeks following their discharge (no. 12, p. 67). In the case of postpartum discharge, better follow-up seems to lower the risk of a return either to emergency or to hospital. It also seems that delayed follow-up is associated with a greater risk of depression among mothers (no. 8, p. 49). Finally, for mental-health patients, there seems to be an association between the availability of a well-developed community network and the increased well-being of this clientele (no. 14, p. 75). Creation of integrated-services networks We observe deficiencies in community-based care that are the result of poorly developed integrated-services networks. Yet, better organized networks are known to provide better results. We thus note that, in mental health, well-organized community networks are supposed to succeed in meeting the needs of these patients and in reducing the frequency and length of their stays in hospitals (no. 14, p. 75). It appears particularly difficult to establish links between the different levels of care (no. 10, p. 60). No one denies the importance of developing interpersonal relations and collaboration based on expertise (no. 9, p. 53), but creating these networks remains difficult (no. 4, p. 33). The main obstacles identified are: shifting objectives, divergent interests among actors, (no. 9, p. 53), lack of trust based on competence (no. 10, p. 60), poor coordination (no. 10, p. 60; no. 9, p. 53), and the absence of mechanisms to coordinate collective action (no. 10, p. 60). The lack of trust among establishments and professionals surfaces in several studies as a constantly recurring factor preventing inter-professional and inter-organizational collaboration (no. 5, p. 35; no. 6, p. 40; no. 7, p. 45; no. 8, p. 49; no 10, p. 60; no. 9, p. 53; no. 12, p. 67). Yet, these combined conditions are essential to any successful transfer of clienteles (no. 2, p. 27). In that respect, the SIPA project (no. 17, p. 88) is particularly revealing in the light it sheds on the benefits a system of integrated services can bring to the elderly, while also demonstrating the feasibility of setting up a first-line organization to provide care to a group of individuals. The SIPA project is coordinated by a case manager working with a multidisciplinary team. Though only preliminary, the project's results demonstrate what a noticeable effect an integrated network can have in reducing hospitalization, placement, and length of stay in emergency. Research Collective 15

22 Hospital-centredness In several projects, hospital-centredness appears as an obstacle to developing networks of integrated services and to enhancing the role played by CLSCs, notably in the delivery of services after discharge from hospital (no. 4, p. 33; no. 5, p. 35; no. 8, p. 49; no.10, p. 60; no. 12, p. 67; no. 14, p. 75). As already mentioned, hospitals are very reluctant to relinquish their authority j personnel have for their counterparts in CLSCs. Hospital-CLSC overlap This mistrust leads to a certain overlap in the services provided between hospitals and CLSCs. We earlier pointed out the case of postpartum follow-up (no. 8, p. 49; no. 10, p. 60). This overlap is also found in the area of home technologies (no. 5, p. 35) and in mental health (no. 14, p. 75). Erosion of the prevention-promotion mission of CLSCs Several findings converge in this sense (no. 5, p. 35; no. 6; no. 7). As the switch to ambulatory care has pressured them to provide more post-hospital services or replace hospitals in providing home care, CLSCs have felt squeezed between their prevention-promotion mission and that of delivering the new services demanded. It would appear that these added services are being delivered to the detriment of the CLSC's prevention-promotion mission (no. 5, p. 35; no. 6, p. 40; no. 7, p. 45) and this pressure from the external environment is creating enormous tensions within CLSCs. Evidence of effective measures In the context of the search for effectiveness and efficiency, two projects propose new means of treatment to reduce hospital stays and improve clinical results (no. 11, p. 63; no, 13, p. 72). They have to do with treatments for strokes and heart failure. These two studies raise questions about the organization of care by illness and population. One of these questions is: Can these two approaches co-exist in the same system? The experiment reported for heart failure very clearly shows that approach by illness is probably more suitable at the second-and third-line level, whereas the approach by population is more appropriate to first-line coverage, as demonstrated in the SIPA project (no. 17, p. 88). 16 Research Collective

23 Health effects Substituting day surgery for intrahospital care does not seem to have had a negative impact on patients health nor on natural caregivers, nor on costs (no. 15, p. 79). We also note that reduction of the length of hospital stay for so-called tracer factors has had no significant impact either on patients health or on the psychological well-being of their natural caregivers (no. 16, p. 82). The greater deterioration in physical health (after hospitalization) among medical patients in 1999 as compared with 1996 might be linked to the increased seriousness of the cases rather than any negative outcomes of treatments (no. 16, p. 82). Finally, from 1999 to 1996, there was a drastic drop in participation in this study; refusal to participate might be linked to a certain degree of frustration expressed by the candidates approached (no. 16, p. 82). Research Collective 17

24 CHAPTER 5 Conclusion 18 Research Collective

25 The objective pursued by this research collective was to identify the possible effects of the transformations carried out in the Montreal-Centre region and to provide decision-makers with elements on which to base more enlightened actions. We grouped together 17 projects using a variety of methodologies and asking a variety of questions about the transformations of the network. A cross-sectional analysis of these projects allowed us to discover the following salient points: The reform was more concerned with reducing resources than with reorganizing services. It has required major efforts, especially on on the the part part of of hospitals, to to implement the measures the measures pro proposed. posed. Success in shortening hospital stays stays and and increasing day day surgeries has has varied varied from from hospital to hospital, but the reduced availability of of hospital beds has left left all all hospitals with with little room to maneuver. Increased day surgeries and shortened hospital stays (for both surgical and medical cases) have not had any negative impact on on the the physical or or psychological health health of patients of patients and and their natural caregivers. The greater deterioration in the physical health of medical patients after their discharge from hospital in 1999 as compared with 1996 seems to be linked to the the increased increased seriousness of cases. of cases. In the public's perception (especially among non-users of health services), there has has been a a general decline in in the the accessibility of of health health services, services, especially especially regarding regarding unreasonable unreasonable delays for appointment and waiting times. The use of services has increased, except among semi-dependent and low-income people who who have have reduced their their demand demand for for the services the services pro provided by hospitals by hospitals and and specialists. Contrary Contrary to to expectations, the use the of use emergency of emergency rooms rooms has continued has continued to grow. to grow. There are particularly noticeable deficiencies in in the community-based care provided to to elderly elderly patients patients discharged discharged from emergency, from emergency, postpartum postpartum women, women, and mental-health and patients. The patients. numerous The obstacles numerous to the obstacles creation to of the these creation networks of these stem networks from hospital-centred stem from hospital- system and centred a mutual system lack of and trust a mutual between lack CLSC of trust and between hospital personnel. CLSC and Similarly, hospital personnel. we note the Similarly, difficulty we the note elderly the experience difficulty the in elderly finding experience a family in doctor. finding We a family also note doctor. overlaps We also in postpartum note overlaps follow-ups, in postpartum home technologies, follow-ups, and home mental technologies, health. Finally, and mental some of health. the negative Finally, effects some of the inadequate negative follow-up effects of have inadequate repercussions follow-up on have the rate repercussions of return visits on the to rate emergency of return made visits by to the emergency elderly and made mental-health by the elderly patients and as mental-health well as on the patients mental as health well as of on postpartum the menta women. health In this of respect, postpartum the SIPA women. project In this offering respect, integrated the SIPA service project to offering groups of integrated dependent service seniors to coordinated groups of by dependent a case manager seniors is coordinated already making by a case noticeable manager reductions is are already in hospital makin use, placement rates, reductions and length in of hospital stays in use, emergency. placement rates, and length of stays in noticeable emergency. In CLSCs, the delivery of of ambulatory-care services is is increasing to the to the detriment of the of the prevention-promotion mission. There are effective ways of providing care in cases of heart failure and strokes that could be extended be extended to the to population the at large. at large. Research Collective 19

26 In conclusion, we can make the following proposals based on our findings: It is important to consolidate first-line services and to avoid potential duplication. It is also important to to develop networks of of services integrating by-illness and and by-population population approaches. Thought must Thought be given must to be developing given to developing appropriate appropriate strategies to strategies attain this to goal approaches. and attain to this incorporating goal and to into incorporating our system into incentives our system favouring incentives these favouring organisational these modes. organiza tional modes. The mission of CLSCs must be clarified, particularly with regard to the role they must play in integrated-services networks and in prevention-promotion. New effective and efficient methods of care of care and and treatment treatment must must be implemented be implemented on a on a population-wide basis, methods like those proposed in the care and treatment of heart failure and failure strokes. and strokes. 20 Research Collective

27 CHAPTER 6 Synopses of research projects Research Collective 21

28 1. Effects of the health services reorganization on emergency department overcrowding Researchers: Danièle Roberge, Raynald Pineault, Pierre Tousignant, Sylvie Cardin, Danielle Larouche Objective To assess implementation of the plan and its effects on the evolution of overcrowding in the emergency departments of Montreal hospitals. More specifically: (1) to document and analyze the degree of implementation of the measures needed to shift to ambulatory care in participating hospitals; (2) to analyze what influence the level of implementation has on the use of beds and stretchers in the emergency rooms of these hospitals; (3) to identify the contextual factors affecting the implementation level and the effects observed. Link with the reconfiguration/reform of health care With what issues is your research project concerned? This project touches on the chronic and persistent problem of overcrowding that Quebec s emergency departments have been experiencing for several years. Similar problems seem to be surfacing in other Canadian cities following transformations of the health system. Decision-makers and managers are finding it difficult to identify the priority actions and durable solutions required to solve this problem. Therefore, it is important to gain a better understanding of if and how major changes in the way services are delivered can have an impact on emergency rooms. Using the appendix to identify the specific reconfiguration measure(s) concerned: M EASURE: Research Collective

29 Research strategy and method This is a multiple case study with a chronological data series (pre & post announcement of Montreal s reconfiguration plan) on the evolution of: (1) the implementation of measures introduced by hospitals to support the shift towards ambulatory care; (2) various indicators of use of short-term-care beds in medicine and surgery; and (3) various indicators of use of stretchers in emergency departments. Hypothesis One of the reform s postulates stipulates that the expected improvements in hospital performance produced by the shift to ambulatory care will: (1) relieve the pressure of hospital closings on the demand for care in the hospitals that remain open; (2) stabilize, and even improve, the situations in emergency departments. This postulate is based on expectations of a perfectly coordinated network of services. The general hypotheses are: The more efforts hospitals make in shifting to ambulatory care, the greater the production of hospital resources The transfer of activities to ambulatory care will entail an increase in the severity of cases and a decrease in the available bed reserve to react to fluctuations in demand. We will observe, on average, an increase in the length of stay on stretchers and greater overcrowding in emergency departments following the introduction of the regional plan for the reorganisation of services. Variables studied Dependent: Various parameters tracking the use of beds and stretchers (average stay, volume of admissions, rate of occupancy, etc.) Independent: Exhaustivenes, intensity and timetable of the implementation of measures to make the shift to ambulatory care in each participating hospital. Contextual: Organizational characteristics (e.g. level of specialization of care, size of hospital, proximity to closed hospitals, bed management and emergency services policies, closing of beds) possibly affecting variations in the degree of implementation of the measures and the observed effectson the evolution of the situation in the emergency departments. Research Collective 23

30 Sample The sample is composed of general and specialized hospitals in the Montreal region. They were selected so as to take into account two factors: whether they were located close to or far from closed hospitals and the degree of overcrowding they were experiencing before the regional reorganization plan was announced. Size of sample 6 hospitals Collection and sources of data Implementation of the measures (type, timetable) needed to shift to ambulatory care and their contextual characteristics were documented by means of a postal survey, then backed up by interviews with directors of professional services and nursing in each of the participating hospitals. An indicator for the intensity of implementation was developed with the help of experts who used explicit criteria to reach a consensus concerning the importance of each of the measures. The evaluative data on the use of beds and stretchers were drawn from Med- Echo files and the provincial emergency room registry. Evolution of the beds actually available in the participating hospitals was documented with the help of either their record department or admitting office. Face-to-face interviews are planned with key informers in each of the participating hospitals in order to document their perception of the effects that the shift to ambulatory care has had on the evolution of the emergency room situation. Type of analysis Analysis of the cases is based on the method proposed by Yin (1994). Each of the cases first undergoes a thorough descriptive analysis including the various sources of data. A crosssectional analysis of cases is then carried out. Finally, an explanation of the processes by which the measures implemented produce the effects observed is proposed. The explanation is finally validated by the advisory committee and representatives of the participating hospitals. Timetable Beginning and end of study: January 1998 to March Research Collective

31 Results particularly relevant for decision-makers (results currently available) There are important inter-hospital differences in the number and nature of the measures implemented, the chronology of their implementation, and the intensity of the efforts made in the process. The shift to ambulatory care had (in varying degrees) already begun in all the hospitals studied even before introduction of the regional plan to reorganize services. The implementation profile of general-care hospitals differs from that of specialized hospitals. Serious progress (though varying by hospital) has been made in increasing the performance of hospital services (e.g. increased volume of ambulatory services, shortened hospital stays). The most remarkable progress has occurred in hospitals that started out with the poorest performance records The evolution of the various indicators of bed utilisation shows a slowdown (even a halt) inthe progress made in hospitals that were quicker to shift to ambulatory care. This slowdown may, at least in part, be attributed to the increased severity of the cases. In the wake of the budget cuts imposed on hospitals, some of the hospitals studied have experienced a serious drop in the available number of their short-term-care beds. Hospital closings combined with the increased severity of cases have considerably reduced, or even eliminated, any room the hospitals might have had to manoeuvre when faced with fluctuations in demand. How conclusive can decision-makers consider these data to be? CATAGORY SECTION OF RESULTS Not at all Slightly Moderately Highly X X X Totally X Research Collective 25

32 Funding sources FCRSS, FRSQ, minstère de la Santé et des Services sociaux, Régie régionale de Montréal-Centre. Expected benefits or utility for planning and decision-making C LIENTS: Managers of policies and programs (MSSS - Régies) B ENEFITS: The study will provide new and useful information on the importance and the nature of the efforts made by hospitals to make the shift to ambulatory care as well as on the effects of budget cuts on the evolution of the actual availability of beds in these hospitals. The study will provide relevant information on hospital characteristics favouring or hindering the implementation and its impact on emergency departments. The study will propose avenues of solution to the systemic problem of emergency room overcrowding. 26 Research Collective

33 2. Transfer of dependent clients from CRPDIs to the Verdun Champlain-Manoir CHSLD Researcher: Militza Zencovich Objective To evaluate the transfer of dependent clients living with an intellectual disability, and being served (in an institutional setting) by rehabilitation centres for the intellectually disabled, to the Champlain-Manoir long-term-care hospital in Verdun. Link with the reconfiguration/reform of health care The plan foresees the transfer of 103 mentally disabled clients to long-term-care hospitals. These transfers will depend on the agreement of the clients and their families and on the evaluation of their needs. In order to ensure personalized and quality services to the persons being transferred to long-term-care hospitals, a pilot project was done in 1998 for the purpose of evaluating the specific needs of these persons and the type of activities to be organized in response to their needs. Research strategy and method The goal is to evaluate the process of implementation and analyze satisfaction in terms of intermediate results. Hypothesis This type of study does not require any a prior hypothesis. The goal is to evaluate the success of the project in terms of its correspondence to initial expectations. Variables studied Variables of the administrative type centred on the stages of a transfer and variables concerned with the satisfaction of clients, relatives, and professionals. Sample All of the 20 clients concerned were studied, along with the representatives of all the organizations involved. Research Collective 27

34 Data collecting instrument A questionnaire to analyze the transfer process and another to measure client satisfaction were developed. These instruments are included in the appendix. Timetable October 1998 to March 1999 Results particularly relevant to decision-makers These transfers were made to rationalize use of CRPDI housing resources and to ensure that the needs of the clientele would be met. The evaluation revealed that well planned transfers involving properly supervised and trained staff can produce results suitably adapted to client needs and generate a high level of satisfaction. How conclusive can decision-makers consider these data to be? Highly. Funding sources Régie régionale, Programming and Coordination Department. Expected benefits or utility for planning and decision-making The evaluation allowed us to confirm that transfers of clientele can be carried out in the best interest of the clients if strict procedures are followed in preparing the setting and the caregivers to welcome the new clients. The process described in the study will serve as a model in supervising and following up on future transfers. 28 Research Collective

35 3. Evaluation of the impact made on accessibility by the reconfiguration of Montreal-Centre's network of health services Objective Researchers: Raynald Pineault, Léo-Roch Poirier, Ronald Lebeau, Véronic Ouellette. To evaluate the impact of the reconfiguration of Montreal-Centre's network of services on their real and perceived accessibility as well as on utilization profiles. Link with the reconfiguration/reform of health care With what issues is your research project concerned? Maintenance of accessibility to professional and hospital services despite modification in the offer. Role played by the media in the way reconfiguration is perceived. Using the appendix to identify the reconfiguration measure(s) concerned. MEASURE EASURE: Research strategy and method Two-component telephone survey stretching over 3 years: the population component covered three independent representative samples; the clientele component was composed of a cohort of patients hospitalized in for certain slowly evolving chronic conditions. Hypotheses Modifications in the offer of services should not affect the accessibility of services. Specifically, persons suffering from chronic disorders should see their access to services maintained. Research Collective 29

36 Variables studied Dependent: Use of services, perception of delays for access to various services, accessibility measures during the last consultation, opinion of health system and of the reform Independent: Modifications in offer of professional and hospital services Concomitant: Sources of information on the reform Sample Population component: probabilistic sample of Montreal-Centre residents 18 and over and capable of answering a telephone survey in French or in English, stratified (nonproportionally) according to 20 federal electoral ridings. Clientele component: voluntary participation of patients hospitalized in in one of the eight participating hospitals representative of the different geographical sectors in the region (four of these eight hospitals closed their doors during the period studied). Size of sample Population component: 1996, n = 1029; 1997, n = 1027; 1998, n = 1025 Clientele component: 1996, n = 863; 1997, n = 443; 1998, n = 333 Collection and sources of data Questionnaire developed by the research team Telephone interviews lasting on average 15 minutes Type of analysis Quantitative analysis based on Chi-square statistical tests and analysis of variance Timetable Interviews conducted respectively in 1996, 1997, and Research Collective

37 Results particularly relevant to decision-makers (Results currently available.) 1. Modifications in profiles of use did not always turn out as foreseen in the transformation plan (in particular, increased visits to emergency rooms). 2. An 11% increase in the use of health services of all types. 3. Increased (but still modest) use of CLSC services. 4. Reduced use of hospital services, of visits to specialists, and of hospitals by semi-dependent and low-income clients, seeming to indicate a greater decline in the accessibility of services for the most vulnerable groups. 5. A fair majority of respondents considered that accessibility had deteriorated: longer waits to obtain services and, above all, the increased frequency of delays judged unacceptable. 6. In all three periods of the study, 40% of respondents said they were not well informed about the reform. 7. Unfavourable positions expressed in the media have also influenced the population along the same lines. How conclusive can decision-makers consider these data to be? CATEGORY SECTION OF RESULTS Not at all Slightly Moderately X X X X X X X Highly Totally Research Collective 31

38 Sources of funding PNRDS Expected benefits or utility for planning or decision-making C LIENTS: Managers of policies and programs (MSSS - Régies) B ENEFITS: Review of communication strategies during implementation of major changes 32 Research Collective

39 4. Implementation and operational assessment: coordinating CHSCDs - CLSCs - attending physician; post-hospital care - administrative dimension Researche: Carole Lécuyer Objective To evaluate the level of implementation of the procedures for coordinating CHSCDs-CLSCs proposed in the regional framework negotiated with the actors concerned. To assess the level of satisfaction among partners regarding inter-establishment operations in view of pinpointing accomplishments and areas needing improvement. Link with the reconfiguration/reform of health care In the continuum of physical health services, the plan foresees the following measures: to increase one-day care, notably to reach 100% of each hospital s potential for the number of day surgeries (measure 1.1.9); to ensure a 20% (8.6 days) reduction in the average stay (measure ); to increase home-care services provided by CLSCs to patients after hospitalization (measure 1.1.1). Research strategy and method The goal is evaluation of implementation and process. Hypothesis This type of study does not require any a priori hypothesis.. Variables studied Variables of the adminstrative type centred on pre-defined methods and variables related to satisfaction of professionals. Sample The study included all the CHSCDs (22) and CLSCs (29) in the region. Research Collective 33

40 Collection and sources of data A postal questionnaire was addressed to persons in charge of following up on procedures in the establishments. We asked these persons occupying strategic positions in their organizations to give a rundown on the opinion of the various actors involved in inter-establishment coordination. All of the establishments answered. These tools are accessible upon request. Timetable February 1997 to August 1997 Results particularly relevant to decision-makers The evaluation showed that the essential coordination procedures were up and running and that the roles defined had generally been respected. Despite this strengthening of inter-establishment links, much remains to be done and the improvements needed have already been identified. How conclusive can decision-makers consider these data to be? Highly conclusive. Sources of funding Régie, programming and coordination department Expected benefits or utility for planning or decision-making The evaluation provided those in charge of inter-establishment coordination with guidance concerning the problems to be solved and the tools to be developed in order to strengthen links between CHSCDs and CLSCs and to offer greater continuity of services to the clientele. 34 Research Collective

41 5. User friendliness and organizational framework of home technologies Researchers: Pascale Lehoux, Raynald Pineault, Lucie Richard, Jocelyne St-Arnaud, Henk Rosendal Objectives To identify, from the viewpoint of professionals as well as patients and caregivers, the technical and human factors affecting the home use of four technologies (antibiotherapy, oxygen-therapy, dialysis, and parenteral nutrition). To identify the organizational factors favouring their integration into CLSC home-care programs. Link with the reconfiguration/reform of health care Issues: Appropriation by CLSCs of technologies favouring the shortening of hospital stays or making home-care feasible for chronically ill patients. Perception of patients, caregivers, and professionals concerning the user-friendliness of these technologies and their use at home. Links between the user-friendliness of the technologies and their use in a concrete context. MEASURES EASURES: To increase post-hospital services in CLSCs To shorten the average hospital stay To increase capacity of home-care services To increase home- and community-based services Research strategy and method Multiple case study. The four technologies were selected because they affect the health of a large number of people, are expensive, and underlie different models of substitution to conventional care. Qualitative data (interviews and observations) and quantitative data (survey) were collected. Research Collective 35

42 Hypotheses The concept of user-friendliness focuses on on pre-requisites of of clinical effectiveness such as the as technical and human factors influencing real-world use of technologies. Recognizing that use evolves the technical with time and human and practice, factors influencing this concept use allows of technologies. us to touch Recognizing on an important that use facet evolves of the switch with time to ambulatory and practice, care: this the concept fact that allows patients us to and touch their on caregivers an important are expected facet of the to become switch to users ambulatory of technology. care: the fact that patients and their caregivers are expected to become users The of technology. more organizationally structured the CLSC, the more appropriately does it succeed in The integrating more organizationally the technology structured into their home-care the CLSC, program the more (professional appropriately training, does it succeed patient raining, integrating coordination the technology of follow-up, into level their home-care of care, etc.). program (professional training, patient. Variables studied User-friendliness: technical (reliability, simplicity, ease of use, etc.) and human aspects (skills, understanding of interfaces, integration in routine of user, etc.). Organizational framework: intra-organizational factors (budget, size and composition of providers team, content of program, etc.) and inter-organisational factors (presence of a liaison agent and committee, transfer of information, sharing of responsibilities, etc.). Collection and sources of data Questionnaire surveying heads of home-care programs in all Quebec CLSCs (n=140-excluding Health Centres in the Grand Nord). Semi-structured interviews with managers (n=20) and professionals (n=20) in a sample of CLSCs (n=20), backed up by periods of direct observation (n=15). Interviews with patients (n=15) and caregivers (n=15) using the technologies studied. Type of analysis Questionnaire - descriptive statistics. As of 7 September 2000 there was a 70% rate of response. Interviews and periods of observation: qualitative analyses. Content analysis of mixed type: pre-defined codes and emerging codes of analysis. All the qualitative material was analyzed using NUD*IST software. Timetable April 1999 to May Research Collective

43 Results 1. There is wide variation in the exposure of CLSCs to the four technologies. 2. The number of patients varies depending on technologies and CLSCs. The number of patients using antibiotherapy IV ranges from one to 300 patients per year and seems to correlate with the number of years the CLSC has been in operation. Very small numbers of patients (1-20) are observed to use parenteral nutrition and dialysis. TABLE 1: CLSC HAVING HAVING DISPENSED SERVICES OVER THE LAST FIVE YEARS YEARS (N=98) TECHNOLOGY DISPENSED OVER LAST FIVE YEARS DIRECTLY RELATED SERVICES INDIRECTLY RELATED SERVICES Antibiotherapy IV By gravity By programmed pump By bottle Oxygen-therapy With concentrator With portable cylindres Parenteral nutrition Peritoneal dialysis Hemodialysis N % N % N % TABLE 2: NUMBERN OF PATIENTS, BY TECHNOLOGY, OVER THE PAST YEAR TECHNOLOGY SERVICES OFFERED ON SITE SERVICES OFFERED AT HOME N CLSC Average Minimum Maximum N CLSC Average Minimum Maximum Antibiotherapy IV Oxygen therapy Parenteral nutrition Peritoneal dialysis Research Collective 37

44 The majority of respondents perceive an increase in the number of patients under antibiotherapy IV and under oxygen-therapy, whereas a significant proportion (19%) perceive a decrease in the number of patients under antibiotherapy (table 3). Slightly more than one half of the respondents believe that the number of patients under dialysis and parenteral nutrition is stable. Table 3. Perception of evolution of the number of clients since 1996 ABLE 3: PERCEPTIONP OF EVOLUTION OF THE NUMBER OF CLIENTS T ABLE CLIENTS SINCE 1996 TOTAL STABLE INCREASING INCREASED THEN DROPPED DROPPING OTHER N % N % N % N % N % Antibiotherapy % 64 72% 12 14% 4 5% 0 0 Oxygen therapy % 56 84% % Parenteral nutrition % 7 27% 1 4% 1 4% 2 8% Peritoneal dialysis % 17 33% 2 4% 2 4% 1 2% Organizationally, integration of technologies seems to be strongly influenced by factors external to CLSCs, notably the roles and strategies chosen by hospitals in delivering ambulatory care and home-care programs. However, among the 20 CLSCs studied in greater detail, six more strongly proactive ones have managed to negotiate special protocols with hospitals which allow them to play a larger role in the use of technologies. Though professionals in 14 of the CLSCs are ready to offer services linked to the four technologies, they feel that post-hospital or curative services are entering into conflict with their community and preventive mission, even in a context where financial and human resources are limited. Based on the quality of the data obtained concerning the number of patients (table 4), it would seem that several CLSCs lack access to a system of information allowing them to know how many patients are using one or more of the four technologies. T ABLE ABLE 4: CLSCS UNABLE UNABLE TO STATE THE NUMBER OF PATIENTS HAVING BEEN OFFERED CARE REQUIRING ONE OR MORE OF THE TECHNOLOGIES TECHNOLOGY HOME-CARE SERVICES ON-SITE SERVICES Antibiotherapy IV Oxygen therapy Parenteral nutrition Peritoneal dialysis 14% 16% 45% 36% 27% 26% 42% 36% 38 Research Collective

45 How conclusive can decision-makers consider these data to be? CATEGORY SECTION OF RESULTS Not at all Slightly Moderately X X Highly X 0 X X 0 Totally Sources of funding Main source: Canadian health research institutes Secondary sources: MSSS Agence d'évaluation des technologies et des modes d'intervention en santé (AETMIS) Expected benefits MSSS, régies régionales et Association des CLSC et CHSLD. This study confirms the wide variation existing in the use of the four technologies by CLSCs on the provincial and regional scale. Procedures (costs, support technique, training, travel, etc.) allowing patients access to these technologies also vary. Given the (still dominant) role of hospitals and the geographical distribution of CLSCs, the services of the latter are used by few patients. It would therefore be wise to explore the relevance of concentrating specific services in certain CLSCs. Managers and professionals in CLSCs. Our findings indicate that it would be preferable for CLSCs to target the technologies they wish to use so as to ensure that their personnel are adequately trained and motivated to maintain their newly acquired skills. Managers and professionals in hospitals Our study suggests that in certain regions hospitals take the place of CLSCs in offering antibiotherapy programs for ambulatory care. The evaluation provided those in charge of inter-organizational coordination with guidance concerning the problems to be solved and the tools to be developed in order to fortify links between CHSCDs and CLSCs and to offer greater continuity of services to the clientele. Research Collective 39

46 6. Promotion and prevention (PP) CLSC services in the field of perinatality-childhood-youth: profile and study of determinants Objectives Researchers: Lucie Richard, Danielle D'Amour, Jean-Marc Brodeur, Raynald Pineault, Louise Séguin, Jean-François Labadie, Robert Latour To draw a detailed portrait of PP services provided by CLSCs in the fields of perinatality-childhood-youth. To examine the association between organizational and environmental factors, on the one hand, and the PP services delivered by CLSCs in the fields of perinatality-childhood-youth on the other hand. Link with the reconfiguration/reform of health care With what issues is your research project concerned? Capacity of CLSCs to meet their prevention-promotion objectives in a context of the re-orientation of their resources to the ambulatory sector. Using the appendix to identify the reconfiguration measure(s) concerned. Measure: Research strategy and methods This research project has two components: a comparative study and a case study. The first component is quantitative and touches on all the CLSCs. Its goal is to describe the PP services (objective 1) and identify the factors associated with their production (objective 2). The second (qualitative) component is based on the data collected in the first component. It involves an in-depth analysis of the processes and dynamics related to the production of PP activities (objective 2) by means of a case study. Hypothesis A CLSC's capacity to provide PP services will depend on the characteristics of the region it serves as well as on those of its organisational structure. 40 Research Collective

47 Variables studied Dependent: Production of PP services (diversity of PP themes covered, diversity of community development activities, innovation in PP themes covered, clientele targeted [general Vs specific]) Independent: Characteristics of the environment (socio-demographic and socio-health aspects, presence of other organisations offering PP ) and organizational characteristics (number of establishment s missions, size and age of the CLSC, collaboration with other organisations offering PP, public health and childhood-family-youth expenditures) Concomitant: s/o Sample Comparative study: n=146 CLSCs targeted (the rate of response to the different questionnaires ranges between 44% and 69%) Case study: n = 2 CLSC Collection and sources of data Comparative study: Three inventories of services for the following age brackets: 0-to-5; 6-to-11; and 12-to-17. A questionnaire on community development activities. A questionnaire on organisational characteristics. Case study: Semi-structured interviews and analysis of documents. Data from the survey and the case study, census data, data from the Groupe d'experts en organisation clinique jeunesse (the Lebon Committee), data from the Association des CLSC et CHSLD du Québec. Type of analyses Comparative study: Descriptive analyses, correspondence analyses, univariate analyses Case study: Qualitative analysis Research Collective 41

48 Timetable Start of field study: April 1999 End of field study: October 1999 for the survey and July 2000 for the case study Tabling of report: November 2000 Results particularly relevant to decision-makers Though identified in principle as generally relevant and important, several of the PP themes listed in the inventories of services turn out to be scarcely touched on by the CLSCs. And in many cases, this limited offer is not compensated for by the activities of other organizations in the community. Thus, according to our data, a considerable number of CLSC territories lack access to any activity linked with priority themes such as early stimulation, safety/unintentional traumas, physical activity, development of social skills Our results also show that the establishments touching on the largest proportion of important themes tend to be larger in size (in the case of themes related to the 0-to-5 and 6-to-11 age groups), located in territories with a more favourable socio-health profile (0-to-5 age group), and that are more urbanized (6-to-11 age group). For all three age groups, collaboration with external partners in delivering or planning activities emerges as a positive factor. Simultaneous consideration of two types of offer-clsc offer (alone or in partnership) and exclusive offer by other community organizations-makes it possible to highlight the distinctive profiles or types of establishment. Two observations emerged from this exercise: For each of the age groups, there exists a group of CLSCs that definitely score lower on the proportion of PP themes covered, when we look at both their activities and those of other organizations in the territory. Our findings show, at least in the case of 6-to-11 year olds, that these establishments tend to be smaller and located in relatively underprivilege rural/semi-urban regions. Several establishments operate in a context where the services offered exclusively by other community organizations play an important role. In certain CLSC territories, more than half the themes are exclusively covered by other organizations. This profile for delivering services can prove very interesting because of the opportunities it creates for the community (job creation, empowerment of community actors, etc.) as well as for the CLSC, which is freed to redirect its resources to other projects. 3. Several of the activities related to the themes have been identified as frequently reserved to specific clienteles. Appearing here as more prevalent in services targeting 0-to-5 year olds, this practice falls in line with the provisions contained in the recent statement from the Council of Public Health Directors concerning preventive measures for those in the 0-to-5 and 6-to-17 age brackets. The offer of services to these specific clienteles is here shown to more the prerogative of larger establishments (themes: 0-to-5 & 6-to-11) located in an urban setting (12-to-18 year olds). 42 Research Collective

49 4. As for innovations, our findings suggest, at least for the 0-to-5 and 6-to-11 age groups, that the larger urban establishments tend to to gravitate toward the themes considered the most innovative. Our results also show a positive association between this dimension of of the offer and the funds derived from the Canadian Perinatal Nutrition program (themes 0-to-5). 5. The profile brought out regarding community development activities confirms the the dynamismof of CLSCs in this sector. Several of of the the activities directly target the the problems experienced by by 0-to-18 year olds olds and and their their families. families. Given Given the the role role these these activities activities play in play stimulating in stimulating inter intersectorial action, action, improving improving living living conditions, conditions, and creating and creating healthy healthy environments, environments, they must they be must seen be as seen key as elements key elements in PP in services. PP services. Comment As the findings of the case study had not yet been validated when these lines were being written, we present here only the results of the comparative study (component 1). For more detailed information on the cases, readers are invited to contact Danielle D'Amour, head of the research on component 2. How conclusive can decision-makers consider these data to be? CATEGORY SECTION OF RESULTS Not at all Slightly Moderately X Highly X X X Totally X Sources of funding Canadian Foundation of Research on Health Services; MSSSQ; Conference of Quebec RRSSS; Montreal-Centre RRSSS; Quebec City RRSSS; Montérégie RRSSS; CLSC Côte-des-Neiges Research and Training Centre. The project also greatly benefited from its collaboration with the Association des CLSC-CHSLD du Québec and the Groupe d'experts en organisation clinique en matière jeunesse (Lebon Committee). Research Collective 43

50 Expected benefits or utility for planning or decision-making C LIENTS Managers of policies and programs (MSSS - Régies) B ENEFITS The portrait of the CLSCs PP services in perinatality-childhood-youth will help managers of ministerial and regional bodies as well as those working in CLSCs to achieve a cleaer view of the variations in the services offered in this type of establishment. Thanks to this profile, they will be able to propose the adjustments required in terms of the PP themes to be covered, the services to developed, and/or the clienteles to be reached. The findings on factors associated with the production of these services will fuel reflection about the means to help CLSCs pursue their PP objectives. Managers of organizations (hospitals, CLSCs, etc.) Idem Professional associations/orders Community groups Findings will provide them with indications about CLSC activities in community development (discussion tables, contribution to development of community organizations, involvement in lobbying). Such data will fuel reflection during planning sessions held by these groups (to determine objectives, establish partnerships, etc.). Others 44 Research Collective

51 7. Impact of health system's reconfiguration on the organisation of preventive services offered by CLSCs in the Montreal-Centre region Researchers: Léo-Roch Poirier, Patricia Goggin, Natalie Kishchuk Objectives To describe the impact of ongoing transformations in the Montreal-Centre region on preventive practices in CLSCs. To identify the organisational and contextual characteristics explaining the variations observed from one establishment to the next. Link with the reconfiguration/reform of health care With what issues is your research project concerned? Broadening the mandate and expanding the services offered by CLSCs Integrating preventive practices into first-line services Keeping people in their home environment as long as possible Use the appendix to identify the reconfiguration measure(s) concerned. MEASURE: Research strategy and method Study of multiple longitudinal cases based mainly on qualitative data. Hypothesis Certain characteristics in the internal and external environment would tend to favour maintenance of the CLSC's promotion/prevention mission. Research Collective 45

52 Variables studied Dependent: Maintenance of promotion/prevention mission. Independent: Characteristics of the external and internal environment of CLSCs. Concomitant: Year created, relative level of poverty in territories served, supplementary budgets to pursue prevention-promotion priorities. Sample Volunteers selected based on three selection criteria (year of creation, relative level of poverty in territories served, supplementary budgets to pursue prevention-promotion priorities). Size of sample 8 Collection and sources of data Semi-structured interviews with general directors and their assistants, then with program heads. First interviews in the beginning of 1997 to size up the situation, a second series in the spring of 1999 to look back over all the changes observed. Group discussion with family aides in the summer of Interviews, analysis of documents, group discussion. Type of analysis Qualitative Timetable Beginning of field work: January 1997 End of field work: June 1999 Final report: September Research Collective

53 Results particularly relevant to decision-makers 1. Negative effects mainly perceptible in the home-care sector. 2. The early-retirement program has had an impact equal to all the measures foreseen in the transformation plan put together. 3. The absence of funding for the development of infrastructures and supervision of new personnel has resulted in budget choices affecting certain preventive programs. 4. The anti-hepatitis B vaccination campaign for youth has entailed a substantial reduction in other preventive and promotional activities in schools. 5. Mixed feelings about the impact of budgets allocated for regional promotion-prevention activities, both as regards the criteria governing their application and their long-term impact on practices. How conclusive can decision-makers consider these data to be? CATEGORY SECTION OF RESULTS Not at all Slightly Moderately X X X Highly X X Totally Research Collective 47

54 Sources of funding Montreal-Centre Public Health Department Expected benefits or utility for planning or decision-making C LIENTS: Managers of policies and programs (MSSS - Régies) B ENEFITS: Account taken of possible indirect damages caused in certain sectors by reforms or special programs affecting other sectors or other programs Managers of organizations (hospitals, CLSCs, etc.) Importance of providing resources for clinical support; an important adaptation strategy is to use work organisation tactics 48 Research Collective

55 8. Evaluation of the impact of postnatal follow-up procedures on mother and newborn in the context of early obstetric discharge Researchers: Lise Goulet, Danielle D'Amour, Raynald Pineault, Louise Séguin, Jocelyn Bisson Objectives To describe the services received by mothers in the postnatal programs offered to them after early discharge from obstetrics and to evaluate their impact on: (1) the health and well-being of the mother and her newborn; (2) the length of breast feeding; (3) mother's evaluation of the services she and her newborn have received; and (4) the subsequent use of health services.. Link with the reconfiguration/reform of health care The Régie régionale is recommending improvement of the coordination of postnatal follow-up between obstetric hospitals, CLSCs, and the attending physician (measure 1.1.1). Research strategy and method Health survey (cross-sectional study) conducted in May/June Hypothesis A short stay in obstetrics will not have any negative impact on the health and well-being of either the mother or her newborn if adequate follow-up is done in the first two weeks following the return home. Variables studied Dependent: The physical health of the mother and her newborn, the mother's mental health, the length of breast feeding, the use of health services by the mother and her newborn (calls to Info- Health, medical consultations, recourse to emergency and hospitalization services), and the mother's opinion of the services she has received. Independent: Characteristics of the services received: nature of the service (telephone call, home visit, appointments in hospitals, CLSCs or private clinics), waiting period (between the return home and the service received), source (hospital and/or CLSC), and level of utilization (number of visits, calls or appointments). Concomitant: Length of hospital stay, socio-demographic characteristics of the mother, informal social support, and recourse to community organizations. Research Collective 49

56 Sample The criteria of admissibility were the following: Fluency in French or English Delivery at 36 weeks of gestation or more No services from a midwife during pregnancy Vaginal delivery without complications (DRG 372.1) Single-birth delivery of a baby weighing 2300 grams or more A postpartum hospital stay of 60 hours or less The sample was composed of 1157 mothers residing on the Island of Montreal and having given birth in one the Island s 9 hospitals. Collection and sources of data A telephone survey was conducted by the CROP polling firm one month after delivery. The CES-D scale (abridged version - 12 items) was used to assess depressive symptoms in mothers. Type of analysis Bivariate statistical analyses and multivariate modeling. Timetable The project was started in November 1998 and ended in October Research Collective

57 Results particularly relevant to decision-makers 1. During the period and for the population studied, the average postpartum hospital stay stood at 46.1 hours (deviation: 5 to 60 hours), varying from 41.9 hours to to 50.4 hours on on average, depending on the hospital % of the mothers received postnatal follow-up either in in the the form form of of a a telephone call, call, home visit or appointment in a hospital, a clinic or the CLSC. 3. For 33.3% of mothers, follow-up consisted of only a telephone call. 4. Follow-up provided by CLSCs: 92.9% of mothers were followed up by their CLSC, the percentage varying between 45% and 100% depending on the CLSC territory. 88.9% received a telephone call (41% to 100%) and 44.4% were visited by a nurse (8.2% to to 89.6%). The The average wait for a visit was 7.1 days. 5. Follow-up provided by hospitals: 56.0% of mothers were followed up by the hospital (4.7% to to 79.3% depending on the hospital); 37.5% received a telephone call (0.0% to 71.1%) and 23.3% returned to the hospital with their newborn for a routine examination (4.5% to 70.6%). In 50% of cases, the mothers returned to hospital in the first week following their discharge. Three profiles stand out as to the type of follow-up provided by hospitals: certain hospitals make few telephone calls but prefer to have mothers and their newborns make a return visit (n=3), others do most of the follow-up by telephone (n=4), and a minority provide practically no follow-up (n=2). 6. Global follow-up: 95.3% of mothers received a telephone call from a nurse affiliated with a hospital or a CLSC after returning home. The average wait or the telephone call is 4.5 days after discharge. 67.1% of mothers had postnatal follow-up through direct contact: either a home home visit visit from from a CLSC a nurse nurse or or a hospital a appointment or or both. both. 7. Duplication of services:on on the the whole, 51.4% of mothers were followed-up by by both their hospital and their CLSC % of babies and 0.8% of of mothers were were readmitted to hospital to hospital during during the first the first month month fol following lowing their their return return home. home. During During the the same same period, period, 24.8% 24.8% of mothers of mothers consulted a doctor a doctor for for a a health problem in in their their babies. 9. Mothers having received a home a home visit visit are distinguished are distinguished from others from by others a significantly by a significantly higher higher percentage percentage of: health of: problems health problems in their babies in their (39.2% babies against (39.2% 33.0%), against 33.0%), emergency emergency visits for visits a for health a health problem problem in the in mother mother (3.1% (3.1% against against 1.4%), 1.4%), and high and scores high scores on the on abridged the abridged CES-D CES-D (3³13) ( 13) scale (22.4% scale (22.4% against against 13.4%). 13.4%). 10. The percentage of mothers with a high score on the abridged CES-D ( 13) (313) scale is significantly higher when the the follow-up is is late (in the second week): 24.0% compared to 13.6% when the first contact (telephone call or direct contact) is made within the first two days following discharge and 20.9% when the contact is made between 3 and 7 days after discharge (Chi-2 linearity: p=0.004). ). The The association holds after after adjusting ajusting for the mother's characteristics. carhacteristics. Research Collective 51

58 How conclusive can decision-makers consider these data to be? Though obtained by telephone interviews with mothers, these data can be classified in the category Highly since they refer to precise events and were collected shortly after the events in question. Sources of funding The FCRSS, FRSQ, Régie régionale de la santé et des services sociaux de Montréal-Centre, Ste-Justine Hospital and Centre hospitalier de l Université de Montréal. Expected benefits or utility for planning or decision-making Decision-makers should pay particular attention to the following findings: Duplication of services for a considerable proportion of clients. Variations in the average stay from hospital to hospital. Programs of postnatal follow-up centred sometimes in the in the community and and sometimes sometimes in hospital. in hospital. Proportion of mothers visited and waiting period for follow-up whether by by telephone or or by by direct contact. This reality does not correspond to to the the norms proposed by by the the various authorities (pediatric ities (pediatric associations, la Régie la Régie régionale régionale de la de santé la santé et des et des services services sociaux sociaux de de Montréal- Montréal-Centre and ministère and de ministère la Santé de et la des Santé Services et des sociaux). Services sociaux). Higher prevalence of symptoms of depression a month after delivery in mothers whose first follow-up contact came late. 52 Research Collective

59 9. Strategic analysis of the implementation of a network of perinatal care 24 Danielle D'Amour, Lise Goulet, Raynald Pineault, Karina Daigle Objective To analyse postnatal follow-up in the framework of a network of perinatal care and to evaluate how well this follow-up covers mothers and their newborns who return home after their discharge from hospital. Link with the reconfiguration/reform of health care The Régie advocates the establishment of an interactive network of services linking hospitals, CLSCs, and medical clinics. The establishment of these networks is a complex operation demanding concerted collective action (measures 1.1.1, 1.1.5, ). Research strategy and method Study of multiple cases (5 cases). Two cases come from the Montreal region and three from outside of Montreal. A case is defined as the whole set of relationships existing between the network s partners: a third-line hospital, a second-line hospital, and a CLSC all involved in the follow-up of normal mothers and their newborns, or those with problems, who return home after discharge from hospital. The data are qualitative in nature and they are collected from semistructured interviews with managers and clinicians (nurses and doctors). Hypotheses An interactive network of health services is being built up through a complex process of constructive collective action. This collective action has an impact on the quality of care provided to the clientele (integration of services) and on the coordination of professional work. 24 Two warnings: (1) development of this perinatality network is underway and (2) the analysis of data is preliminary. Research Collective 53

60 Variables studied Characteristics of the network: history, size, centrality, complexity, and connectedness. 2. Characteristics of the organisation: mission, orientations, quantity of resources, number of deliveries, development of professional resources. 3. Process of collaboration and inter-organisational coordination, analysis is based on four dimensions: a) degree of network's formalization, (b) degree of finality: common finalities and procedures for reinforcing and evaluating collaboration, (c) feeling of belonging to the network, (d) delegation or authorities appointed to pilot the network. 4. Quality of care: defined in terms of continuity of care, accessibility, promptness in providing care, and longitudinal aspects (pre and postnatal). 5. Coordination of professional work: satisfaction and solidarity (building a common ground on which to acquire knowledge, transfer experience, and develop skills). CHARACTERISTICS OF THE NETWORK History Size Complexity Connectedness CHARACTERISTICS OF THE ORGANISATION Mode of delivery of care Number of clients On-the-job training Perception of quantity of resources Quality control AN ORGANIZATIONAL MODEL FOR THE ANALYSIS OF A NETWORK OF PERINATAL CARE PROCESS OF COLLABORATION AND INTER-ORGANISATIONAL COORDINATION Interiorisation Finalization Formalisation Delegation Administrative Coordination Clinique Coordination QUALITY OF CARE Continuity of care Accessibility Early delivery of care Longitudinal aspects COORDINATION OF PROFESSIONAL WORK Satisfaction among professionals Feeling of solidarity Danielle D'Amou, PhD (August 2000) 25 Findings related to the characteristics of the network and the organization are not presented in the present document. 54 Research Collective

61 Participants studied The cases are viewed as compendiums of the relationships between professionals and managers involved in the three levels of care. Participants come from the three types of institutions and from the five cases studied. The cases have been selected on a regional basis: four socio-sanitary regions are represented. Front-line hospital CLSC Second-line hospital 14 INTERVIEWS WERE CONDUCTED WITH 17 MANAGERS AND CLINICIANS PARTICIPANTS HOSPITAL CLSC TOTAL Managers Clinicians Total no. of participants Instrument for collecting data The interviews were conducted using a grid documenting all the variables in our reference framework. Other sources of data Med-Écho data bank, findings of the research by Goulet, D'Amour, Séguin, and Pineault (in progress) on early discharge in obstetrics in the Montreal region. Type of analysis Each case was individually analyzed and then subjected to a cross-sectional analysis. Timetable May 1999 to Octobre 2000 Research Collective 55

62 Results particularly relevant to decision-makers Our data show that building a network involves setting up mechanisms to coordinate the network's various partners. 1. Our data show that two types of actors help in building a network: administrative personnel and clinical personnel. Administrative personnel assume two main responsibilities: (1) negotiation of of a a formal and and consensual agreement and (2) establishment of steering bodies establishment that will facilitate of steering the application bodies that of the will agreement facilitate the by application clinical personnel. of the agreement Clinical personnel by are clinical responsible personnel. for carrying Clinical out personnel the agreement are responsible and providing for carrying fee back out to the managers agreement on how it is and working. providing feedback to to managers on on how it it is is working. 2. Our data show that working in a network depends on the establishment of a formal network among the partners. This is is the principal and sometimes the the only only mechanism providing a a framework in which the different actors can operate. In both of the cases we studied where there was an agreement it had evolved out of a process in which the actors got to to know and trust each other. This This agreement was was also also the result the result of a negotiation of a negotiation between between the partners the partners involved. involved. 3. Our analysis of five cases in the field of perinatality shows that in all five cases there is is no no agreement between second-and-third-line second-line services, nor between nor between thiand front-and-third-line first-line services. services. However, However, in two of in the two five of cases, the five an agreement cases, an does agreement exist between does exist second- between and front-andsecond-line services. Therefore, services. as Therefore, things now as stand things in now the stand network in the (whose network development, (whose development, we will recall, we first-line will is still recall, in progress), is still in out progress), of a total out of of 15 a total possible of 15 agreements, possible agreements, we can identify we can only identify two. only two. 4. Our data show that there may be several reasons explaining this absence of of agreements: (1) Distance Distance between between with organizational cultures (2) Competition between between institutions (3) Geographical distance distance (4) Lack Lack of of knowledge about about working working a in network a network and and about about the the advantages it offers it offers (5) Lack Lack of interest of interest on the on the part part of actors of actors (6) Too Too many many partners partners Where an agreement exists, we find strong coordination. Lack of any agreement formalising the shape of the network seems to be associated with weak coordination. 56 Research Collective

63 In the milieus with strong coordination (1 st and 2 nd lines) we find: A sharing of the responsibilities arising from orientations related to the shift to ambulatory care; this means that home care care is is mainly provided by by CLSCs CLSCs rather rather than than second- second- or or third-line hospitals. A consensus on follow-up procedures (telephone, visit) and little or no duplication of services. Adequate mechanisms of of communication and and their their effective effective use, use, resulting resulting a in larger a larger proportionof of inter-establishment referrals for vulnerable clientele. Professionals concerned express their satisfaction with the quality of information exchanged. In both cases where there is strong coordination between front- and second-line services, mothers are systematically called after their return home and systematically visited by a CLSC nurse. In the three other cases where there is is weak coordination between front- frontand second-line institutions, mothers are are systematically called called but but are are not not systematically systematically visited at home. Out of these three cases, one one of of the the hospitals hospitals systematically offers offers mothers mothers an appointment an appointment and the other and the two other do so two if the do so need if the arises. need According arises. According to participants, to participants, lack of lack coordination of coordination lowers the lowers accessibility the accessibility of services. of services. Longitudinal aspects aspects (continuity (continuity between between pre- pre- and and postnatal postnatal services) services) receive receive greater greater attention in the two cases where there is strong coordination: referral resources are more often used. However, respondents tell us us that that the the mechanisms still still need need improvement, and this is being studied and discussed. Participants in the two milieus with strong coordination indicate that that the the clientele giving giving birth in the third-line hospital could receive adequate local local follow-up, but but deplore deplore the the fact fact that that the third-line the third-line centre centre takes takes care care of its of own its own follow-up follow-up with with an an on-site on-site appointment. In both cases where there is is strong coordination, administrative authorities have established procedures allowing personnel to get to know each other personally and to to receive training as a group. The personnel has been given the the opportunity to to exchange knowledge and and expertise. Respondents stress the importance of of these collective endeavours: the the time time and and energy invested in them are essential to collaboration. These remarks apply particularly to nurses, who seem to have fewer occasions for exchange than doctors. According to the partners, collaboration has has generated more more adequate adequate use use of of resources resources and allowed CLSCs to re-appropriate the perinatal activities they had been forced to give up. Research Collective 57

64 In the milieus with weak coordination (1 st and 2 nd lines) we find: A duplication of services (notably telephone calls from both the hospital and the CLSC; both home visits by the CLSC and hospital appointments). Professionals are dissatisfied with both written and verbal mechanisms of communication. Inadequate communication mechanisms and and the the resulting lack lack of information of information stop stop professionals from ensuring continuity of of care and and services. They They are are dissatisfied with with the the information at their at their disposal. disposal. The longitudinality (pre-and postnatal) is not often taken into account. Referral mechanisms are seldom if ever used. Serious conflicts between the hospital and the CLSC over the sharing of responsibilities. Few mechanisms to provide uniformity of care from one health institution to to the the next and and to ensure to ensure the continuity the continuity and and coherence coherence of care of care and and teaching. teaching. Participants from different health institutions saying that they neither know their fellowprofessionals nor anything about their areas of competence. This situation is is at at the the root root of serious problems of lack of trust, notably as concerns the competence of the personnel. Lack of trust stemming from the failure to to know and and recognize the the competence of fel of fellow low professionals has has been been identified as as a a particularly obvious barrier between thifront- front-and third-line services. Partners are relatively dissatisfied with inter-organizational inter-organisational links in the perinatality network and have trouble seeing what such a network has to offer them. How conclusive can decision-makers consider these data to be? On the whole, we could qualify the results as moderately conclusive. They emerged from our understanding of the practices and relationships among those involved in building the network (professionals, managers, clinicians), based on their own perceptions. Sources of funding FASS project evaluating the Ste-Justine Réseau Mère-Enfant Supra Régional (RMESR: Mother-Child Network), perinatality component. 58 Research Collective

65 Expected benefits or utility for planning and decision-making Research findings reveal the serious challenges facing decision-makers and managers as regards the creation of networks in the health field. It also reveals the potential impacts that flaws in such a network might cause. The research findings offer decision-makers information responding to certain questions arising from the global evaluation of the Ste-Justine Mother-Child Network: Does Does building a a network improve the the quality and and effectiveness of of services (clinical component)? What What is is the the network's impact on on the the use, use, offer, offer, and and accessibility accessibility of services of services (population (population component)? component)? What is the network's impact on the costs associated with the use and offer of the services What concerned is the network's (economic impact component)? on the costs associated with the use and offer of the services concerned What are the (economic determinants component)? and impact of the variations in implementation of the network What (organizational are the determinants component)? and impact of the variations in implementation of the network (organizational component)? The research does not provide in-depth answers to all of these questions but does offer elements of response to each of them: The findings show that the the level level of of coordination between the the network's network's partners partners has an has an impact on its effectiveness and efficiency. This was particularly apparent between first- and second-line services. For a clientele returning home directly from a third-line health institution, the gulf separating partners at different levels of of intervention shows shows the the difficulty experienced in ensuring ensuring the the continuity and efficiency and efficiency of services of services and probably and probably occasions occasions private private travel travel costs costs for the for the clientele. The findings identify certain conditions needed to implement a a network, among which the the two most important seem to to be be formalisation formalization of of inter-organisational inter-organizational agreements and and establishment ment of relationships of of trust. of trust. The The network is is called on to perform a complex task task which requires the setting up up of of concrete mechanisms whose first first goal goal must must be be the the quality quality of rela- of relationships between between the the interdependent members members of the of the network. network. It would seem important to to seek deeper understanding of the of processes the processes governing governing interorganizational inter-organisational collaboration collaboration and the mechanisms and the mechanisms required to required encourage to this encourage type of collaboration of collaboration which is only which in its infancy. is only in its this type infancy. Research Collective 59

66 10. Diabetes project: evaluation of the implementation of an integrated-services model for patients suffering from diabetes in the Côte-des-Neiges district Researchers: André-Pierre Contandriopoulos, Danielle Larouche 4, Rosario Rodriguez 9, Raynald Pineault 7 Objective Evaluation of the implementation of the integrated-services model for diabetic patients is aimed at understanding the processes of inter-professional and inter-organizational collaboration initiated with this new model. More specifically, we are attempting to assess: (1) the interest aroused by the project in participating organizations; (2) the level of trust, consensus, willingness to collaborate and satisfaction reflected in inter-professional and inter-organizational relations; (3) the development of procedures and formal links; and (4) changes in medical practices. Link with the reconfiguration/reform of health care Physical health: development of interactive networks and development of ambulatory care to improve comprehensiveness and continuity in the care provided to patients suffering from chronic illnesses. (measure: 1.1.4) Research strategy and method Case study. Content analysis of semi-structured individual interviews with participating doctors, non-participative observation and analysis of documents. Confirmation des propositions How the model is being implemented. Verifying that the model favours integration of the actors involved through: better support for doctors, transfer of information, communication among actors, closer adherence to guidelines, changes in practices related to changes in patients. Variables studied Synthetic analysis of a health-care model 60 Research Collective

67 Sample Diabetic patients in treatment with 44 participating doctors. 12 clinics, doctors offices, or family medicine units. More than 250 patients registered with the project (receiving the project s initial evaluation and services). Timetable The FASS-funded part of the project ended in December All the activities evaluating implementation follow the same timetable. The final report will be tabled in March Begun in autumn 2000, evaluation of the project's effects will continue for 2 years. Results particularly relevant to decision-makers (see table 1 on page 62) How conclusive can decision-makers consider these data to be? Highly Sources of funding Funds for adaptation of health service (FASS) dedicated to analysis of implementation. Canadian Health Services Research Foundation (CHSRF) dedicated to analysis of the effects. Expected benefits or utility for planning or decision-making For managers of policies and programs, managers of professional organizations and associations: Knowledge about the implementation of an integrated-care model. The difficulties and opportunities doctors experience with the implementation of integrated practices; what favours networking among doctors. What can be improved in the care provided to diabetic patients. What can be improved in the patient s follow-up and monitoring of his or her own diabetes. Possibility of applying these lessons to other pathologies of a chronic nature. Research Collective 61

68 TABLE 1. PRELIMINARY FINDINGS Perceived role of doctor: to recruit patients for the project Interest in participating: mainly to share roles and responsibilities INCENTIVE TRUST Private Practice: Possibility of offering better care and access to resources. Establishment: Participation in development of a new model of care and support for medical research. Increasing incidence of diabetes. Based on leadership and expertise of implementation and evaluation teams. CONSENSUS COLLABORATION COLLABORATION Importance of interpersonal relations between members of the multidisciplinary care team. Time constraints lower satisfaction and involvement in the project. Congruence in philosophy of care. In development. Difficulties in developing a common vision of care among members of the team. Requires modification of the role of the doctor. SATISFACTION IMPACTS Relations established with the contact nurse. Affected by the quality and promptness of information feedback and by operational barriers. Leads us to rethink our practices. Opportunity to participate in activities of a scientific nature. Improvement of knowledge about the disease and its treatment. Development of a more global perspective on the disease. Increased value placed on home monitoring of glycemia. Increased adherence to CDA guidelines. Better access to specialists. Reduced attrition of follow-up visits by patients. Extra work caused by patients recruitment, checking files and learning the system. Challenge of adapting to the dynamics of a work in progress. ATTITUDE OF PATIENTS Beginning to monitor and compare results of glucose tests. Like using the glucometer. Better informed. Like access to a nurse and a dietitian. Trust in their doctor favours recruitment. Limits to participation: illiteracy, lack of fluency in English or French, age and living alone. 62 Research Collective

69 11. Cost-effectiveness of early supported discharge for stroke Researchers: Nancy Mayo, Josephine Teng, Sharon Wood-Dauphinee, Robert Côté, Eric Latimer, James Hanley Objective To estimate the cost-effectiveness of early supported discharge with home-based rehabilitation. Link with the reconfiguration/reform of health care With what issues is your project concerned? To increase post-hospital services (in CLSCs) To reduce the average stay in hospital (DMS) To increase the capacity of home care ($21.4M) Use the appendix to identify the reconfiguration measure(s) concerned: MESAURES ESAURES: Research strategy and method Randomized clinical trial. Hypothesis Early supported discharge combined with home-based rehabilitation services will be more effective and less costly than usual care practices for providing post-acute stroke care. Research Collective 63

70 Variables studied Dependent: Health-related quality of life (SF-36), reintegration into the community (RNL index), IADL (OARS), BADL (Barthel index), direct costs. Independent: Home rehabilitation group, usual care group. Concomitant Stroke severity for cost analysis only. Sample Persons admitted for acute stroke to five acute-care hospitals in Montreal with persistent motor deficits following stroke, who had caregivers willing and able to provide live-in care for the subject over a four-week period following discharge from hospital. Stroke patients who, 28 days post-stroke, still required the assistance of more than one person to walk were excluded as were patients with cognitive impairment or with important co-existing conditions affecting their ability to function independently. Size of sample 58 subjects assigned randomly to the home-care group and 56 subjects assigned randomly to the usual care group. Collection and sources of data Initial evaluation of physiotherapists with the help of questionnaires based on performance and interviews (conducted before randomization, four weeks after treatment, and three months after random assignment). The following measurements were used: SF-36, RNL index, OARS- IADL, Barthel index, Timed-up and Go and Stroke Rehabilitation Assessment of Movement, length of stay in acute care hospital and in rehabilitation, cost of hospitalization, visits to emergency and to a doctor, and rehospitalizations. Direct evaluation of participants, examination of medical files, data from the RAMQ (Quebec Health Board) on use of services. Type of analysis Fixed-effects, repeated measures model with missing data using generalized estimating equations (GEE) for evaluation of effectiveness data and t-test for cost analysis. 64 Research Collective

71 Timetable From 1996 to 1998 Results particularly relevant to decision-makers 1. At At the three month evaluation, the the HOME group had had a mean a mean physical health health score score significantly significantly by greater 5 points by 5 higher points than higher the than USUAL the USUAL care group. care group. greater 2. Both groups improved significantly over time on measures of impairment (STREAM and TUG) and BADL. The home group was not not any any worse than than the the usual usual care care group group on these on these measures. measures. There There was a was significant a significant favourable favourable effect effect of the of home the home intervention intervention measures on measures of IADL of IADL and and re-integration. 3. The duration of of stay in in acute-care was shorter by three days, a significant difference for the home group HOME (mean group 9.8 (mean days, 9.8 SD days, 5.3 days) SD 5.3 compared days) compared with the with control the group control (12.4 group days, (12.4 SD days, 7.4 days). SD When 7.4 days). duration When of stay duration in rehabilitation of stay in rehabilitation hospitals for hospitals persons in for the persons usual care in the group USUAL is included, group the difference is included, becomes the difference greater: becomes mean of greater: 16.1 days mean (SD of days) (SD for the 14.6 control days) group. for the care control group. 4. There were fewer readmissions in the HOME home group than than in in the the USUAL care care group group (12 (12 vs. vs. 22). 22). The time spent in hospital following re-admission readmission was also shorter for for the the home home group group compared with the usual care group (247 (247 days days vs. vs days). days). As a As result, a result, the average the average cost cost per readmission per readmission for the for HOME the home group group was substantially was substantially lower than lower the control than the group control ($654 group vs. ($654 $2211). vs. $2211). 5. The cost of of home care itself came to to an an average of of $988 per subject. 6. On average, the intervention group had fewer physician visits (general practitioner and and specialist visits) compared with the usual care group. 7. The final average total cost for the home group was was significantly lower lower than than the the USUAL usual care group ($ vs $ ). Although, virtually all services use used was cost less less expensive for the in home the group, HOME the group, major the reason major for reason this differential for this differential was that was the home that the group home had group fewer had readmissions, fewer and missions those for that a occurred substantially were shorter for a substantially length of stay. shorter length of stay. How conclusive can decision-makers consider these data to be? CATEGORY Not at all Slightly Moderately SECTION OF RESULTS Highly X X X X X X X Totally Research Collective 65

72 Sources of funding NHRDP Expected benefits or utility for planning and decision-making C LIENTS: Managers of policies and programs (MSSS - Régies) B ENEFITS: Prompt and intensive home-rehabilitation by qualified stroke professionals should be provided to all patients leaving hospital with deficits. The cost of the intervention is more than absorbed by savings in terms of emergency room and physician visits and re-admissions. Managers of organisations (hospitals, CLSCs, etc.) Vertical integration of health care services should be offered for persons with stroke. In this way the hospital can arrange the best package of care for patients, provided by the most highly qualified personnel. Community groups Continue to lobby for post-acute stroke services. 66 Research Collective

73 12. Procedures and perceived quality of care for the elderly in emergency departments: Impact on risk of return visit Researachers: Sylvie Cardin, Raynald Pineault, Danièle Roberge, Eddy Lang, Michel Tétrauft, Josée Verdon Objective Among the elderly, determine the association between: (1) patient management procedures in the emergency department and during follow-up in the community; (2) the perception of the quality of care; and (3) the risk of return visits to the emergency department. Link with the reconfiguration/reform of health care With what issues is your project concerned? One of the goals of reconfiguration is to maintain the elderly in the community. In this perspective, it is important to obtain information on the factors likely to interfere with an eventless and appropriate return home and transfer of the elderly patient to the community after an emergency department visit. Patients and caregivers perception of the quality of care and services is an important dimension when it comes to evaluating the reform. In this project, we attempt to measure perceptions associated with different patient management procedures and the impact of these perceptions on the risk of emergency department return visits. Use the appendix to identify the reconfiguration measure(s) concerned: M EASURE: 1.1.3, Research strategy and method Cross-sectional study in which patients aged 70 or over who made an unplanned return visit to the emergency department within 14 days of an initial visit are compared with patients who did not return. Research Collective 67

74 Hypotheses Given equality of needs, patients adequately prepared for discharge from the emergency department, and having received services from their CLSC, hospital, or family physician soon after their return home will be less likely to make an unplanned return to the emergency department. Given equality of needs, patients (or their caregiver) adequately prepared for discharge from the emergency department, and having received services from the CLSC, hospital, or family physician soon after their return home will have a more positive perception of the quality of care and services obtained. Given equality of needs, patients with a more positive perception of the quality of the care and services obtained are less likely to make an unplanned return to the emergency department. Variables studied Dependent: Unplanned returns, perception of quality of care and services (for certain analyses). Independent: Information given to the patient at the emergency department, evaluation of the patient in the emergency department, prescription and delivery of post-discharge services (CLSC, hospital, family doctor), perception of quality of services (for certain analyses). Concomitant: Frailty, severity, family situation and social support, sociodemographic characteristics, previous use of health services, hospital, rate of occupancy of emergency department. Sample Patients aged 70 or over: (1) seen in the ambulatory or stretcher area of the emergency department of one of four Montreal hospitals; (2) between 1 November 1999 and 31 March 2000 and during one of five nurses shifts (day or night) randomly chosen each week; (3) in stable medical condition; and (4) having been discharged from emergency. Excluded were patients: (1) hospitalized, transferred or sent to a long-term-care hospital after their emergency department visit; (2) whose cognitive status, medical condition or lack of fluency in French or English prevented participation and for whom no proxy was available; (3) who had not been seen by a doctor during their visit to the emergency; (4) who did not reside in Quebec. Sample size : n= 588 patients. 68 Research Collective

75 Collection and sources of data Face-to-face questionnaire administered in the emergency department (eligibility, consent, frailty [ISAR], cognitive status [SPMSQ], severity, etc.) Telephone questionnaire administered in the first days following discharge (sociodemographic variables, comorbidities, previous use of health services, social support, information received in the emergency department, evaluation performed in the emergency department, prescription of post-discharge services, perception of quality of the care and services received in emergency). Telephone questionnaire administered at least two weeks after discharge from the emergency department (returns, urgent medical consultations, hospitalizations, delivery of prescribed services, perception of the quality of care and the services received since discharge, functional autonomy [OARS]). Organisational questionnaire administered to a key informant in each institution. Sources: Patients survey Key informants survey Provincial emergency department database ( Registre des urgences ) Type of analysis Multivariate analyses (logistic and linear regressions). Timetable Sampling: 1 November 1999 to 31 March 2000 End of study: December 2000 Research Collective 69

76 Results particularly relevant to decision-makers (Only the results related to the first hypothesis are available.) 1. 40% of patients discharged from the emergency department had some functional disabilities before the incident that brought them to to the emergency department. Yet, Yet, only only 42% 42% of of the the latter were receiving home care services at the time of their visit, between November 1999 and March % of patients discharged from the emergency department returned unexpectedly within the 14 days following discharge. If we add to this number the unplanned and emergency visits made made to physicians to outside outside the the emergency department, departement, we we can can estimate estimate 15% at 15% (1 (1 patient out patient of 7) the out incidence of 7) the of incidence emergency of medical emergency visits medical made shortly visits made after a shortly stay in after the emergency. a stay in These the emergency. numbers do These not numbers differ statistically do not differ from statistically one hospital from to the one next. hospital to the next % of patients said they had no family doctor available for consultation. Given equality of needs, these patients were times more more likely likely to return to return early early and and unexpectedly to the to the emergency department. 4. Though the majority of predictors of of return are are indicators of of needs needs (functional autonomy, cardiopathy, dementia, etc.), the risk of of early return to to the the emergency department declines considerably (given equal needs) for patients who obtained: 1) information about appointments or tests post-discharge; and and 2) 2) a a referral for for home-care care services services (odds (odds ratio: ratio: 0.39 and , and 0.29, respectively). The same trend is is observed when it it comes to to predicting the the risk risk of of seeking emergency medical care outside the emergency department shortly after a visit. How conclusive can decision-makers consider these data to be? Category Section of results Not at all Slightly Moderately X X (reference) Highly X X X Totally (info) 70 Research Collective

77 Sources of funding FCRSS, FRSQ, CHUM, RRSSS, MSSS Expected benefits or utility for planning and decision-making C LIENTS Managers of policies and programs (MSSS - Régies) B ENEFITS: The results of this cross-sectional study are not conclusive with regard to the changes brought in by the reform. However, they indicate that, in 2000, a problem of access to primary care services still exists. Indeed, that one of the most vulnerable customer groups is not better-equipped in terms of family physicians shows that the reform has not reached its goal yet. The small number of patients receiving home care services after their emergency department visit could also indicate the lack of involvement of the community. The importance of prescribing home care services could reflect the efficacy of the latter but could also be caused by the reassuring effect of knowing that more services are coming soon. Subsequent analyses concerning the obtention of services and perception of the quality of care and services will bring further explanations. Managers of organizations (hospitals, CLSCs, etc.) Specific results concerning the link between the process of patient management in the emergency department (information provided, prescriptions) and returns should be used to adjust discharge planning in different emergency departments. More resources should be spent to identify needs and provide information to elderly patients from the ambulatory area of the emergency department. Professional associations/orders Montreal general practitioners should make themselves more available for elderly patients. Research Collective 71

78 13. Randomized study evaluating the effect of an interdisciplinary program of ambulatory clinical follow-up on the rate of rehospitalization, quality of life, and use of hospital resources among patients with heart failure Researchers: O. Doyon, J. Brophy, J.-L. Rouleau, A. Ducharme, F. Gauthier, M. Langlois, J. Loyer, S. Heppel Objectives To evaluate the effect of treating patients suffering from heart failure with ambulatory care through clinical follow-up rather than traditional care on: (1) the number of rehospitalizations; (2) length of stay; (3) perception of quality of life; (4) reduction of their usual initial stay during rehospitalizations; (5) mortality; (6) compliance with treatment; (7) costs associated with use of hospital services. Link with the reconfiguration/reform of health care Among other things, the Régie proposes to orient services toward less complex resources by decreasing the number of short-term beds, shortening length of stay, and avoiding overcrowding in emergencies (measures 1.1.1, 1.1.3, 1.1.7). We estimate that heart failure represents from 3% to 4% of annual hospitalizations with an average stay of 14.2 days, thus constituting the major cause of hospitalization among the elderly. Moreover, numerous rehospitalizations are often necessary and data drawn from the records reviewed by multicentred and local studies confirm that 30% of patients are rehospitalized within the six months following an initial hospitalization. Heart failure has also been recognized by the Montreal-Centre Public Health Department as a regional priority and by the MSSS as a target for the development of integrated approaches. Research strategy and method Randomized experimental study: comparison of patients in the control group and the experimental group recruited between January 1998 and January 2000 and whose six-month participation in the experiment ended in July Hypotheses An interdisciplinary and ambulatory program of clinical follow-up for patients with heart failure is more effective than traditional outpatient follow-up in: (1) reducing the number of rehospitalizations; (2) reducing length of stay; (3) reducing costs for hospital services; (4) improving both quality of life and (5) compliance with treatment; and (6) maintaining the current rate of mortality. 72 Research Collective

79 Variables studied Dependent: Quality of life; compliance with treatment; rehospitalizations; emergency visits; medical consultations (number, length of stays, primary and secondary diagnosis, seriousness of heart failure, treatments, associated costs, intensity of care); mortality (principal diagnosis, post-hospitalization period). Independent: Ambulatory care in a clinic for cardiac function. Concomitant: Seriousness and length of condition, comorbidity, stressful events. Sample Patients suffering from ventricular dysfunction having come to emergency for an episode of heart failure, no matter what their age or sex, and whose condition requires treatment. Included are: (1) symptomatic patients: dyspnea at rest or with minimal effort or paroxysmal nocturnal dyspnea; (2) patients with clinical signs: heart racing when auscultated or increase in jugular venous pressure or tachycardia or rattles when auscultated; (3) radiological confirmation of pulmonary overload; or (4) recent non-invasive (<6 months) examination of left heart function: electrocardiogramme or examination in nuclear medicine showing a ventricular dysfunction. The following criteria of exclusion were used: (1) patient's inability to sign the consent form; (2) regional place of residence; (3) access to care and follow-up for chronic disease; (4) awaiting imminent heart surgery; (5) heart failure as a side-effect of evolving myocardial thrombosis; (6) participation in another research project; (7) refusal on the part of the attending physician. Size of sample: 230 patients. Collection and sources of data Quality of life: questionnaire Minnesota Living with Heart Failure Questionnaire (University of Minnesota, 1986). Compliance with treatment: Hilbert Compliance Questionnaire (selfreported questionnaire, Hilbert, G., 1988). These questionnaires are administered twice, once during randomization and again after a period of six months. Follow-up form for experimental investigation. Analysis form for medical files. Budget analysis of costs. PRN data: indicators of intensity of direct nursing care. Evaluation grid for patient satisfaction. Contact with patients, medical files, RAMQ data bank, budget information. Type of analysis Univariate analysis using t tests for continuous variables and the chi-two method for categorized variables. Analysis of survival: Kaplan-Meier curve. Cox analysis to correct the ambiguous variables. Research Collective 73

80 Timetable Randomizing: January 1998 to January 2000; follow-up and measurements over a six-month period. End of study: July 2000; validation of data and ongoing analysis. Results particularly relevant to decision-makers Not yet available Number and length of rehospitalizations. Number and length of visits to emergency. Repercussions on costs. Costs and function of follow-up. Effects on quality of life, compliance with treatment, and satisfaction. How conclusive can decision-makers consider these data to be? To be continued... Sources of funding Doctoral studies project O. Doyon: Continuing study at the Université du Québec à Trois-Rivières. Grant from the Merck-Frosst and Smith-Kline-Beecham firms. Expected benefits or utility for planning and decision-making The switch to ambulatory care for surgical clienteles is farther advanced than for those suffering from complex and chronic medical problems. The findings of this project can be of help in the process of switching to ambulatory care in the case of: (1) Decision-makers: who must decide whether to set up this type of clinic and invest human and material resources in it; (2) Managers: who are being proposed an effective, efficient, and satisfactory way of organizing and delivering care which can be adapted to other contexts (exportability); (3) Professionals: who are being proposed standards of care and a model for coordinating professional resources along a strategically continuous line. 74 Research Collective

81 14. Evaluation of the effectiveness of the network of services offered to persons with mental problems who live in the community Objective Researchers: Léo-Roch Poirier, Louise Fournier, Deena White, Céline Mercier, Alain Lesage To verify the degree to which services meeting certain criteria of continuity have a significant impact on the state of well-being of persons with serious and persistent mental problems. Link with the reconfiguration/reform of health care With what issues is your project concerned? Deinstitutionalization Organization of services in the community Integration of services Using the appendix to identify the reconfiguration measures concerned: MEASURE EASURE: Research strategy and method Follow-up of cohorts of patients in three sectors during one year; analysis of the network of services in each of the sectors. Hypothesis The specific configuration of the network of services in each of the sectors will have an impact on the clientele's state of well-being. Research Collective 75

82 Variables studied Dependent: Symptomatology, quality of life, satisfaction of needs Independent: Measurements of the network's density, centralization, and multiplexity. Concomitant: Knowledge and level of use of resources. Sample Cohort of voluntary respondents between 18 and 55 years of age, residing in one of the three sectors under study, who, at the time of recruitment, had just been discharged from a hospital or a crisis centre following an episode; confirmed or presumed diagnosis of schizophrenia and other psychotic disorders or serious mood problems except for disorders induced by a substance. For measures related to the network, representatives of all the resources in each of the sectors were encountered to fill out the questionnaire. Size of sample 150 patients; 160 resources. Collection and sources of data Instruments adapted to and validated within the Quebec context (Basis 32, Wisconsin Quality of Life, Camberwell Assessment on Need) or developed by the research team (knowledge and use of services by patients; the entire questionnaire administered to representatives of the resources). Data collected by interviews (patients and respondents of the resources). Type of analysis Network analysis for the independent variable; covariance analysis for the dependent variable. Timetable Start of field study: Spring 1999 End of field study: Spring 2001 End of study: September Research Collective

83 Results particularly relevant to decision-makers 1. Very preliminary results: There seems to be an association between the presence of a very well developed community network and greater satisfaction of the needs of the clientele. 2. Conversely, a more hospital-centred network would be less apt to meet these needs and would generate more frequent and lengthier stays in hospital. How conclusive can decision-makers consider these data to be? CATEGORY SECTION DE RESULTS 1 2 Not at all Slightly X X Moderately Highly Totally Sources of funding FCRSS Expected benefits or utility for planning and decision-making C LIENTS: Managers of policies and programs (MSSS -Régies) B ENEFITS: Type of organisation of services to favour Identification of deficiencies in offer of services Managers of organisations (hospitals, CLSCs, etc.) Links to be developed with other resources Professional associations/orders Links to be developed with other resources Research Collective 77