RP #4: Implanting service integration to frail elders in the practices of senior administrators, managers, and clinicians.
PRINCIPAL INVESTIGATOR: L Demers.
CO-INVESTIGATORS: Y Couturier, D Malo, D Morin, A Tourigny.
OBJECTIVES: 1) To understand and model a) the rules and practices put forward by CSSS senior administrators in planning, budgeting and organizing services for frail elderly persons and b) how senior administrators, managers and clinicians, frail elderly persons and their family caregivers, adapt a formal service integration model to the local conditions under which it is implemented. 2) To derive and model conditions that foster or inhibit the adoption of planning and budgeting tools, organizational methods, and collaboration practices designed to improve the efficacy and effectiveness of services for frail elderly persons. 3) To use results from these analyses to support the adaptation of integrated care systems for the frail elderly in the CSSS.
METHODS: A multiple embedded case study design will be used. Rules, resources, and practices used to coordinate services for frail elders in three CSSSs territories will be examined. To maximise the scope of our results, we will study three contrasting cases: one in a metropolitan area, one in an urban setting and one in a more rural environment. The case study method will draw upon three different sources of information: interviews, documents and direct observations. The information will be merged and compared through triangulation of methods and informants.
For interviews, a purposive sampling strategy will be used. For each case, we foresee conducting around 12 semi-structured interviews with each of the three following groups of informants: 1) CSSS senior administrators and managers, as well as service providers for frail elderly persons (these interviews will be used to document the governance and management of the system providing services to frail elders); 2) professionals (physicians, nurses, social workers, etc.) working directly with frail elderly persons (these interviews will provide information on how the prescriptive guidelines of the integration model shape professional conduct and, conversely, how the conduct and the logic of clinical action transforms the prescriptive guidelines); 3) elderly individuals receiving care through a case management system and family caregivers. Caregivers will be interviewed whenever elders suffer from cognitive impairment and cannot provide clear information regarding their care.
Direct observations will seek to locate in which circumstances service standards are negotiated at the governance-management level (board and committee meetings) and at the clinical level (case managers meetings, encounters between professionals and elders or family caregivers).
The document review will cover relevant administrative documents related to care integration (formal model used to integrate services, budgets and tools for budgeting, policies and procedures, memorandums of understanding, guidance documents, and services coordination rules). These documents’ analysis will be used to understand the formal rules and setting of the services integration system’s governance and operations. The clinical file of the elderly persons covered by our interviews will also be analysed. This will allow us to compare official rules (what is supposed to be done), discourse about the functioning of the system (what is said to be done), obtained through interviews, and clinical files data on what has actually been done.
EXPECTED RESULTS: The review and cross-sectional analysis of each case will enable us to build an explanatory model of how the prescriptive guidelines of the integration model are adapted to the local conditions at participating CSSSs. Then, comparative analyses between cases will allow discussing the extent to which local adaptation is a major component of the innovation or not.
TIMELINE: October 2007-March 2008: preparation; April 2008-October 2011 fieldwork, analysis and writing of research reports for the governance-management and the clinical parts of the research of the three sites; November 2011-September 2012: cross-sectional analysis of the three cases and writing of the final report.
INSTITUTIONAL SETTING: This project will take place at ENAP-Quebec, U. Laval (Nursing sciences), CDRV (IUGS), U. Sherbrooke (Social work), U. of Montreal (Nursing sciences) and in three CSSSs.