Département de médecine de famille et de médecine d'urgence, Faculté de médecine et des sciences de la santé, Université de Sherbrooke. 3001, 12 Ave North, Sherbrooke, Québec, J1H5N4, Canada; Centre de recherche du centre hospitalier universitaire de Sherbrooke. 3001, 12th avenue North, Sherbrooke, Québec, J1H5N4, Canada.
Faculté des sciences infirmières, Université de Montréal. 2375 Chemin de la Côte-Sainte-Catherine, Montréal, Québec, H3T1A8, Canada.
Health Policy. 2023 Jun;132:104804. doi: 10.1016/j.healthpol.2023.104804. Epub 2023 Apr 3.
Case management (CM) is recognized to improve care integration and outcomes of people with complex needs who frequently use healthcare services, but challenges remain regarding interaction between primary care clinics and hospitals. This study aimed to implement and evaluate an integrated CM program for this population where nurses in primary care clinics worked with a hospital case manager.
A multiple embedded case study was conducted in the Saguenay-Lac-Saint-Jean region (Québec, Canada), in four dyads including a clinic and a hospital. Mixed data collection included, at baseline and 6 months, interviews and focus groups with stakeholders, patient questionnaires (patient experience of integrated care and self-management), and emergency department (ED) visits in the previous 6 months.
Integrated CM implementation was optimal when all stakeholders provided collective leadership, and were supportive of the program, particularly the physicians. The 6-month program enabled the observation of positive qualitative outcomes in most clinic-hospital dyads where implementation occurred. Full implementation was associated with improved care integration.
Integrated CM between primary care clinics and hospitals is a promising innovation to improve care integration for people with complex needs who frequently use healthcare services. Collective leadership and physicians' buy-in to integrated CM are important to foster the implementation.
病例管理（CM）被认为可以改善经常使用医疗保健服务的有复杂需求人群的护理整合和结果，但初级保健诊所和医院之间的互动仍然存在挑战。本研究旨在为这一人群实施和评估一个综合的 CM 计划，其中初级保健诊所的护士与医院的病例经理合作。
在魁北克省的萨格奈-圣让湖地区（加拿大）进行了一项多嵌入式病例研究，包括四个对偶组，每组包括一个诊所和一个医院。混合数据收集包括在基线和 6 个月时，对利益相关者进行访谈和焦点小组讨论，患者问卷调查（患者对综合护理和自我管理的体验），以及过去 6 个月内的急诊部门（ED）就诊情况。
当所有利益相关者提供集体领导，并支持该计划，特别是医生时，综合 CM 的实施是最佳的。该 6 个月的计划使大多数实施发生的诊所-医院对偶组观察到积极的定性结果。全面实施与改善护理整合有关。
初级保健诊所和医院之间的综合 CM 是改善经常使用医疗保健服务的有复杂需求人群的护理整合的一种有前途的创新。集体领导和医生对综合 CM 的认同对于促进实施是很重要的。
