Case management in primary healthcare for people with complex needs to improve integrated care: a large-scale implementation study protocol.

INTRODUCTION: Case management (CM) is among the most studied effective models of integrated care for people with complex needs. The goal of this study is to scale up and assess CM in primary healthcare for people with complex needs. METHODS AND ANALYSIS: The research questions are: (1) which mechanisms contribute to the successful scale-up of CM for people with complex needs in primary healthcare?; (2) how do contextual factors within primary healthcare organisations contribute to these mechanisms? and (3) what are the relationships between the actors, contextual factors, mechanisms and outcomes when scaling-up CM for people with complex needs in primary healthcare? We will conduct a mixed methods Canadian interprovincial project in Quebec, New-Brunswick and Nova Scotia. It will include a scale-up phase and an evaluation phase. At inception, a scale-up committee will be formed in each province to oversee the scale-up phase. We will assess scale-up using a realist evaluation guided by the RAMESES checklist to develop an initial programme theory on CM scale-up. Then we will test and refine the programme theory using a mixed-methods multiple case study with 10 cases, each case being the scalable unit of the intervention in a region. Each primary care clinic within the case will recruit 30 adult patients with complex needs who frequently use healthcare services. Qualitative data will be used to identify contexts, mechanisms and certain outcomes for developing context-mechanism-outcome configurations. Quantitative data will be used to describe patient characteristics and measure scale-up outcomes. ETHICS AND DISSEMINATION: Ethics approval was obtained. Engaging researchers, decision-makers, clinicians and patient partners on the study Steering Committee will foster knowledge mobilisation and impact. The dissemination plan will be developed with the Steering Committee with messages and dissemination methods targeted for each audience.

[Public participation and civic participation of service users in relation to the Mental Health Action Plan 2005-2010: their spokesperson function]. / Participation publique et participation citoyenne des personnes utilisatrices de services en lien avec le Plan d'action en santé mentale 2005-2010: leur rôle de porte-parole.

CONTEXT: Among the guiding principles of the Mental Health Action Plan 2005-2010 (MHAP) of the Quebec Ministère de la santé et des services sociaux (Health and Social Services) is the recognition that persons who use mental health services (consumers) can be active agents of their own individual and collective recovery journey. In accordance with this principle, the MHAP called for greater participation of consumers in local, regional and national decision-making bodies within the network of health and social services in Quebec. OBJECTIVE: The objectives of this article are to look back on the various forms of consumers' participation in connection with the MHAP since its enactment, and to better understand the complexities of being spokespersons through the Actor Network Theory conceptual framework. METHOD: A scientific literature review was conducted. Different angles of analysis were used to highlight convergences and trends based on official governmental publications and ongoing research on consumers' participation in decision and policy making. It was thought that a vertical case study approach would offer an historical perspective going back to the early 1960s to discuss the foundations of an "ideology of participation." Another way of assessing participation is through a horizontal approach that would compare the terms of participation implemented from one regional authority to the other, in order to cover most of the Quebec territory. RESULTS: The MHAP did not provide clear indicators of how to assess progress made with regards to greater consumer participation. In some regions of Quebec, this participation was coordinated by community organizations that designated their representatives. In other regions, local authorities included consumers on a more individual basis to give their opinion. As all were not at the same stage in their recovery process, some were in a position to speak using the "we," while others still needed to express themselves using the "I." In either case, their function as spokespersons proved to be a bi-directional function. In one direction, the spokesperson informed the governmental and institutional stakeholders about the expectations of consumers and about their daily life realities. In the other way, they were able to explain and make more intelligible the intricacies of the system with a lay language, which helped non specialists they encountered to remain informed partners, even though indirectly. As they shared their experience as spokespersons with their peers, their peers were able to get a clearer understanding of the progress made to effectively promote active and effective participation. The lack of clear expectations and dedicated means to support participation, induced discrepancies from one region to another, making it difficult, though, to assess progress made overall. CONCLUSION: As the function of spokesperson got more professionalized with increased opportunities to participate in policy and decision-making, spokespersons spoke from an "us" rather than an "I" standpoint. The concept of public participation evolved to one of civic participation, with the possibility to transcend the "us" and "them" dichotomy, as members of a community are all citizens to one another. Still, the terms and conditions of participation could be better defined and more predictable for greater equity in terms of access to different levels of policy and decision-making.

[New parameters in community treatment practices: the contribution of community and alternative mental health groups in Québec]. / Nouveaux paramètres pour l'élaboration des pratiques de soutien communautaire: contribution des organismes communautaires et alternatifs au Québec.

This article examines the origin and the context of the implementation project of community treatment according to the perspective of community and alternative mental health groups in Québec. The author presents results of a research on practices of these groups through a specific array that integrates the essential components of the community treatment model. The author examines six parameters characterizing devices, approaches and practices: 1) approach in supportive care and attention; 2) voluntary relation with the organization 3) the place of biomedical treatment; 4) flexibility in length and intensity of treatment; 5) the individual and collective dimension of supportive care; 6) and, participation as an active citizen.