Reorganising health and social care in Québec: a journey towards integrating care through mergers (original) (raw)
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Mergers and integrated care: the Quebec experience
International journal of integrated care
As a researcher, I have studied the efforts to increase the integration of health and social services in Quebec, as well as the mergers in the Quebec healthcare system. These mergers have often been presented as a necessary transition to break down the silos that compartmentalize the services dispensed by various organisations. A review of the studies about mergers and integrated care projects in the Quebec healthcare system, since its inception, show that mergers cannot facilitate integrated care unless they are desired and represent for all of the actors involved an appropriate way to deal with service organisation problems. Otherwise, mergers impede integrated care by creating increased bureaucratisation and standardisation and by triggering conflicts and mistrust among the staff of the merged organisations. It is then preferable to let local actors select the most appropriate organisational integration model for their specific context and offer them resources and incentives to c...
Politiques de …, 2009
The quest for greater efficiency in health systems encourages governments to bring together two fields of practice that have largely developed in parallel in industrialized countries: public health and healthcare. Current healthcare reform in the province of Quebec formally integrates these two fields within a common governance structure. The objective of this paper is to discuss the issues arising from the integration of public health services into the planning and delivery of local healthcare services, and its potential effect on the overall performance of the healthcare system. The authors begin by describing the characteristics of these two sectors; then, they discuss current reforms in Quebec and the impact of various transitions (epidemiological, technological and organizational) that bring the sectors into greater convergence. The paper concludes with a discussion of obstacles and potential opportunities at two levels: (a) the development of population-based planning of services within healthcare organizations, and (b) the articulation of public health and healthcare services concerns at the local level. The ongoing reform in Quebec is a unique opportunity to maximize outcomes from the resources invested in the healthcare system, based on a collective vision for improving health.This paper was originally published in French, in the journal Pratiques et organisation des soins 39(2): 113–24.
Quebec’s Family Medicine Groups: Innovation and Compromise in the Reform of Front-Line Care
2009
At their origin, public healthcare systems were designed mainly for the treatment of acute illnesses. For many years, therefore, public health care focused on services offered in healthcare establishments and primary care was allowed to evolve on the periphery of hospitals, with doctors free to follow their own conception of how best to provide and follow up on care. As hospital costs grew, however, and new challenges regarding the provision of care began to emerge, governments felt increasingly responsible for organizing the front line (Nolte and McKee 2008). How doctors would be called upon to participate in the new configuration of services-particularly in Canada, where physicians function as independent entrepreneurs-is the subject of this article, which investigates the decision to introduce family medicine groups (FMGs) to the province of Quebec.
Healthcare Policy, 2009
The quest for greater efficiency in health systems encourages governments to bring together two fields of practice that have largely developed in parallel in industrialized countries: public health and healthcare. Current healthcare reform in the province of Quebec formally integrates these two fields within a common governance structure. The objective of this paper is to discuss the issues arising from the integration of public health services into the planning and delivery of local healthcare services, and its potential effect on the overall performance of the healthcare system. The authors begin by describing the characteristics of these two sectors; then, they discuss current reforms in Quebec and the impact of various transitions (epidemiological, technological and organizational) that bring the sectors into greater convergence. The paper concludes with a discussion of obstacles and potential opportunities at two levels: (a) the development of population-based planning of servi...
Ten years of integrated care: backwards and forwards. The case of the province of Québec, Canada
International journal of integrated care, 2011
Québec's rapidly growing elderly and chronically ill population represents a major challenge to its healthcare delivery system, attributable in part to the system's focus on acute care and fragmented delivery. Over the past few years, reforms have been implemented at the provincial policy level to integrate hospital-based, nursing home, homecare and social services in 95 catchment areas. Recent organizational changes in primary care have also resulted in the implementation of family medicine groups and network clinics. Several localized initiatives were also developed to improve integration of care for older persons or persons with chronic diseases. Québec has a history of integration of health and social services at the structural level. Recent evaluations of the current reform show that the care provided by various institutions in the healthcare system is becoming better integrated. The Québec health care system nevertheless continues to face three important challenges in ...
Interdisciplinary collaboration within Quebec community health care centres
Social Science & Medicine, 2002
Central to the success of many recent health system reforms is the implementation of new primary health care delivery models. The central characteristic common to these new models usually emphasises interdisciplinary collaboration. Using empirical research, this paper studies interdisciplinary collaboration among various groups of professionals within an original Canadian primary health care delivery model, the Quebec Community Health Care Centres (CCHCs). The entire population of more than 150 CHCCs have been surveyed. The goals of this study are (1) to measure the achieved intensity of inter-professional collaboration among Quebec CHCCs, and (2) to identify the organisational and professional factors fostering or limiting interdisciplinary collaboration. The results show that Quebec CHCCs have reached modest results in achieving interdisciplinary collaboration especially since interdisciplinary collaboration is a central objective that has been pursued for more than 25 years. This study demonstrates that the main factors associated with interdisciplinary collaboration are closely linked to work group internal dynamics. Interdisciplinary collaboration is linked to the simultaneous and antagonistic effect of some central intragroup process factors. Conflicting values and beliefs are present that both enhance and limit interdisciplinary collaboration. The presence of conflicting stimuli seriously undermines the strength of the CHCC work group's shared beliefs and strongly limits interdisciplinary collaboration. The results also stress the importance of administrative formalisation initiatives to enhance collaboration among different professions. The efficacy of formalisation in this context is based on its capacity to offer an articulated and operative interdisciplinary framework that can generate a counteractive effect to the traditional professional framework. It offers concrete rules that help align the work group beliefs with interdisciplinary values. The formalisation of functions and processes appears thus to be an interesting means to further interdisciplinary collaboration. r
Institutional Change & the Parapolitics of Community Health Centres in Québec
2001
. Even before the commission report was published, its chairman, Claude Castonguay, entered politics and immediately headed the new Ministry of Social Affairs. He had the unusual privilege of implementing the comprehensive and idealistic systems he and his commissioners had conceived as government consultants. CLSCs were thus introduced in 1971 as part of a thoroughly integrated and rationalized network of health and social care establishments. A simplified organisational chart ( provides some idea of how they fit into this network. In contrast to other provinces, the entire health system is public : hospitals, CLSCs and other organizations are public establishments, each with their own boards of directors, but with mandates, budgets and oversight, the responsibility of what came to be the Ministry of Health and Social Services. The system is made up of central, regional and local institutions, with the CLSCs representing the local level. The principal uniqueness of the system lies not so much in its public nature, as in its rational integration and its intersectoral character. While there are some distinctly health establishments, such as hospitals, and some distinctly social institutions, such as Youth and Child Protection Agencies, others have a mixed mandate -in particular, long-term care facilities and, of course, CLSCs. The enormous legitimacy enjoyed by the Québec government at the time of this initial health reform accounts in large part for the tenacity of the CLSCs. Without such high public support for these sweeping reforms, it would not have been possible to enact the kind of wall-to-wall institutional transformation that eventually turned out to be difficult to dismantle, even in the face of rapid and repeated challenges over the years. Furthermore, government control over this integrated system means that policy and programming decisions generally affect the CLSC network as a whole, rather than one CLSC at a time. It is unthinkable that Québec would today undertake a vast reform of this nature, though there is no doubt that successive governments have benefited over the years from their heightened capacity to manage this integrated sociohealth system and to harness it to both political and health-related objectives. Since 1971, the life course of the CLSCs may be divided into three distinct phases, representing different external conditions and pressures and different internal dynamics. The first phase might be called the decade of experimentation. During the first 5-year period, 70 CLSCs were rapidly established, albeit in great confusion. There was a lack of clarity of with respect to their mandate and internal organisation, with strong divisions between social groups -in particular, between local community activists and ideological professionals -over both these issues as well as others. For, while the CLSCs were originally seen as a project that allied reform-minded politicians, professionals and community groups, this was a fragile alliance with many potential areas for conflict. Furthermore, a long and contentious process of unionizing CLSC staff added to the chaos. After only 3 years of development, an evaluation was desperately commissioned by the ministry and in 1976, majority and minority reports were published, with conflicting views, of course. The minority report (Lessemann & Alary, 1975) represented a more radical view centred on local autonomy, community organization and a preventive, holistic, social approach to primary health, while the majority report preferred to see the CLSC as a more traditional, service-oriented community health centre. The majority report might have been implemented but for two events: first, outrage on the part of the new CLSCs themselves, expressed through their new Federation, for the staff did not see themselves as ordinary service providers; and second, a change of government. The new, more social democratic party in power (Parti québécois or PQ) did not implement the majority report, but neither did it endorse the minority report. Instead, it put a moratorium on the establishment of CLSCs, with the
Canadian journal of public health. Revue canadienne de santé publique
In 2004, the Quebec government undertook a major reorganization of its health care system by integrating public health more formally into local governance structures. In all, 95 new organizations - Health and Social Services Centres (CSSS)--were created and given a population-based responsibility. This mandate required that CSSSs broaden their range of services by adopting a population-based plan and integrating public health into their activities. To accomplish this, they needed to link public health and health care issues more formally within a single governance structure. The aim of this article is to identify and analyze various activities undertaken by CSSS managers to fulfill their population-based responsibility. We conducted a longitudinal case study of two CSSSs (2005-2008). Our analyses are based on real-time observations of 144 meetings of decision-makers/managers and professionals at the regional and local levels, 46 interviews with managers, as well as secondary data. C...
Towards a framework for Primary Health Care Transition in Canada
Main Messages A shared framework is essential to guide the development of Primary Health Care (PHC) in a consistent way across federal, provincial and territorial jurisdictions of Canada. Current reform agendas are implicitly based upon diverse Primary Care (PC) objectives, with a focus on reforms of discrete micro level service organizations. The conceptualization, development and evaluation of PHC, needs to be addressed in order to build upon the First Ministers' Accords commitment to transition Canadians to PHC-based health care systems. The "new orientations" articulated in the Pan-American Health Organization/ WHO PHC Declaration of Montevideo, 2005-and agreed to by the governments of the Americas (including Canada and the USA), as well as the UK. and France-should stimulate each province/territory to review their health systems objectives,and more specifically the future role of primary health care (PHC) in their health system. This paper provides an analysis of the evolution of PHC policies across Canada, emphasizing interconnected and enhanced care for individuals, families and communities, as well as the clinical focus of PC organizations or practices. A PHC framework, based on the 'new orientations' of the PAHO/WHO Declaration of Montevideo is proposed, to guide PHC development and evaluation in Canada. The broader PHC mandate includes addressing health inequities, through empowerment of individuals, families and their communities. Complex systems concepts provide mechanisms to address some important gaps in the current PC-oriented strategies-system concepts and levels, self-organization, evaluation, feedback and improvement. These underpin the proposed framework for adaptive local PHC systems to meaningfully interconnect the different models of service organization in order to address local needs for PHC. Local PHC systems are proposed as a strategy to transform individual PHC organizations into networks of care that collaborate to meet individual, family and community health needs in a local community. PHC systems require regional and provincial frameworks and local coordination so that local organizations can network and adapt delivery to meet community needs. Evaluation strategies must address what are the key leverage points and constraints of a local PHC system in relation to local priorities and the shared PHC framework, with ongoing feedback loops to enable adaptation to changing needs. Evaluation must also ensure comparisons among jurisdictions within Canada and with jurisdictions in other countries. Key Recommendations: A Framework for Adaptive Primary Health Care Systems across Canada is recommended and key elements of this multilayered PHC systems framework are outlined: 1. Future PHC systems would build upon the new orientations of PHC from the PAHO/WHO Declaration of Montevideo with a commitment to promote social inclusion and equity in health through strategies that support the critical roles of individual, family and community empowerment. Provider organizations would be resourced through the PHC system. The authors gratefully acknowledge the comments and inputs of representatives of the Canadian Alliance of Community Health Centre Associations and Joachim Sturmberg and the editorial support provided by Ken Hoffman, Alanna Smith and Peter MacKinnon and general support provided by Kevin Smith.