Providers’ Perspectives on the Implementation of Mandated Local Health Networks for Older People in Québec

Description	Case 1	Case 2	Case 3
Geographical setting	Highly urban area	Urban area	Semi-urban area (urban zones and rural zones)
Total population	421,342	164,666	41,927
Surface area	282 km²	325 km²	5,964 km²
Population density	1,494 people/km²	466.5 people/km²	7 people/km²
Historical context		Historical pilot site for a project on the integration of care for older people in Québec.

Table 2

Providers’ perspectives on the implementation of the clinical dimension of the Local Health Network for Older People.

Component	Case 1	Case 2	Case 3
1) Centrality of client needs	– Focused on the physical, mental, and social aspects of users’ health as indicated by the Multiclientele Assessment Tool. – Difficulties balancing patients’ needs to the services offered.
2) Case management	– Only social workers were “case managers”. – Only nurses are “main providers”.	Any provider (nurse, social worker, occupational therapist) could be a “case manager”.	Social workers or nurses could be “main providers”.
3) Patient education	– Educating patients as part of their informed consent and shared decision-making activities.
4) Client satisfaction	– Providing care for client’s needs with the resources available. – There are no formal mechanisms to measure the client’s satisfaction.
5) Continuity	– Fragmented care still existed in the Local Health Networks, though mechanisms were put in place to facilitate care continuity.
6) Interaction between professional and client	– Patient engagement during shared-decision making and consent. – Administrative and legal obligations such as explaining their roles or duties, sometimes hindered interactions.
7) Individual multidisciplinary care plan	– Creating multidisciplinary individualised care plans for patients. – Variable use of care plans within and across the cases.
8) Information provision to clients	– Variable criteria of access to certain local resources, (e.g. local clinics), sometimes they are not known.
9) Service characteristics	– Services were provided, depending on the individual patient’s needs and the capacity of the Local Health Network. – There were patient waiting lists for some services.
10) Client participation	– Endeavouring to engage all patients in shared decision making, though this was not always possible in practice.
11) Population needs	– Providers were more focused on the needs of the patients than those of the wider population.
Interpretation services were offered for the multicultural population.	Some community organisations offered relief services for exhausted caregivers.	Transport services were needed for patients in rural zones of the territory.
12) Self-management	– Self-management support that aimed at increasing the autonomy of patients were mostly information on local community services.

Table 3

Providers’ perspectives on the implementation of the professional dimension of the Local Health Network for Older People.

Component	Case 1	Case 2
13) Inter-professional education	– Continuous education and inter-professional team work.
Focused inter-professional training activities in the X pilot project.
14) Shared vision between professionals	– Multidisciplinary teams developed the content of care. – Variable and unequal hierarchical team work dynamics, in favour of health care organisations over the other partners.
15) Agreements on interdisciplinary collaboration	– No formal agreement on interdisciplinary collaboration was mentioned. – Shared clinical tools may foster interdisciplinary collaborations. – Heavy workloads discourage interdisciplinary collaborations.
16) Multidisciplinary guidelines and protocols	– Same government-issued planning tool and Multiclientele Assessment Tool (OEMC, Outil d’Évaluation Multiclientèle) in Québec. – Used by different groups of providers (e.g. nurses, social workers, occupational therapists).
17) Inter-professional governance	– Governance structure consisting of health and social care providers who are jointly accountable for services delivered to patients.
18) Interpersonal characteristics	– Equality, trust, and respect between the different partners in a multidisciplinary team. – Previous successful collaboration experiences facilitated current collaborations.
19) Clinical leadership	– No provider stood out as a champion in the implementation of this Local Health Network.
20) Environmental awareness	– Rarely referring to the socio-economic and political climate of their Local Health Network, they seemed to endure the reforms, instead of participating in them.
21) Value creation for the professional	– Capacity-building through regular interdisciplinary collaborations greatly depended on individual providers.
22) Performance management	– Mix-up between organisation performance (defined by management goals and activities volume) and clinical performance (defined by service quality goals). Only organisational performance is considered.
Performance indicators were presented on a monthly basis by team leaders.	Performance was measured based on the activities of the providers, such as the number of completed evaluations.	Performance was measured every three months by team leaders.
23) Creating interdependence between professionals	– Lack of knowledge of activities and situations of other providers usually led to fragmented professional care, though providers sometimes developed interdependent approaches in care delivery (e.g. nurses and nursing assistants).

Table 4

Providers’ perspectives on the implementation of the organisational dimension of the Local Health Network for Older People.

Component	Case 1	Case 2	Case 3
24) Value creation for organisation	– Partners from the community and private sectors provided complimentary services to the public organisations. – Some issues regarding the coherence and management of services delivered by the different partners.
25) Inter-organisational governance	– Not assessed.
26) Informal managerial network	– Not assessed. (Providers had limited knowledge of the governance of their organisations. Few mechanisms to participate in the governance of their organisations.)
27) Interest management	– Favourable organisational climate for the combined interests of the strategic, tactical, and operational levels. – Deplored the frequency and magnitude of changes in their Local Health Networks. – Local community organisations are financially dependent on their public partners, and this may influence their missions and the services they deliver.
28) Performance management	– Few strategies to distribute the workload so as to reach management targets over the fiscal year.
29) Population needs as binding agent	– Inter-organisational collaboration mildly considered the needs of the population. They were more focused on managerial targets of individual organisations, such as reducing waiting lists.
30) Organisational features	Mega-urban Health and Social Services Centre characterised by high population density, multiple organisations, and proximity of specialised services.	Urban Health and Social Services Centre characterised by moderate population density, sufficient number of organisations, and proximity of specialised services.	Semi-urban Health and Social Services Centre characterised by a low population density on a large territory, limited number of organisations, and sparse specialised services.
31) Inter-organisational strategy	– The Local Health Network was organised around the Health and Social Services Centre, which arranges the sharing of some resources (financial, material and human) with its partners. –Two main strategies; administrative mergers of some public organisations, and linking strategies of various partners.
32) Managerial leadership	– Centralisation of decision making powers to the ministry of health and social services.
33) Learning organisations	– Not assessed.
34) Location policy	– Several co-location strategies amongst partner organisations, for example the merger of partner organisations, were thought to be beneficial to their partnerships.
35) Competency management	– Not assessed.
36) Creating interdependence between organisations	– Organisational interdependence occurred through shared responsibility for delivery of care to clients, coordinated by the Health and Social Services Centres.

Table 5

Providers’ perspectives on the implementation of the systemic dimension of the Local Health Network for Older People.

Component	Case 1	Case 2	Case 3
37) Social value creation	– Major structural reforms led to administrative integration that was less felt at the clinical level.
38) Available resources	No major lack of resources.		Lack of sufficient human resources.
39) Population features	– More concerned by the features of their clients than those of the population.
Substantial immigrant population with cultural specificities.	Many isolated older people with poor social networks.	Many older people dispersed over a large territory.
40) Stakeholder management	– Centralisation of decision making powers which created a distance between management and providers. – The Health and Social Services Centre was mandated by government to establish and coordinate partnerships with local community organisations and private organisations.
41) Good governance	Not assessed.
42) Environmental climate	– The three cases shared the same socio-economic and political climate marked by marked by successive health system reforms, raising concerns regarding the benefits of these reforms at the clinical level.

Table 6

Providers’ perspectives on the implementation of the functional dimension of the Local Health Network for Older People.

Component	Case 1	Case 2	Case 3
43) Human resource management	– Administrative mergers facilitate human resources management, but have little impact on the work climate. – Staff of partner organisations often collaborate in care delivery.
44) Information management	– Multiple unaligned health information systems at the operational level.
45) Resource management	– Resources do not always meet the needs of clients. – Funding models focus on the volume of services offered, and do not take into consideration the quality of care.
46) Support systems and services	Not assessed.
47) Service management	– There is coordinated 24-hour assistance for users and providers, facilitated by a unique telephone number and a shared point of access for the Local Health Network. – Various regulations complexify the use of these resources.
48) Regular feedback of performance indicators	Providers were given feedback during monthly meetings with their managers.	None mentioned.	Feedbacks reflected volume of services.

Table 7

Providers’ perspectives on the implementation of the normative dimension of the Local Health Network for Older People.

Component	Case 1	Case 2	Case 3
49) Collective attitude	– Providers are overwhelmed by the frequent structural reforms and their individual workloads.
50) Sense of urgency	– Providers did not understand the need for frequent organisational changes. – They had limited knowledge of the concept of integrated care.
51) Reliable behaviour	– The pertinence of the innovation is lost with the high turnover of providers and managers.
52) Conflict management	– Not assessed.
53) Visionary leadership	– Not assessed.
54) Shared vision	– The main aim of the Local Health Network was to maintain older people with complex needs at home with quality care for as long as possible with the resources available.
55) Quality features of the informal collaboration	– Inter-professional collaborations were mostly satisfactory. It seemed to benefit teamwork. – Managerial-professional collaborations were less satisfactory.
56) Linking cultures	– Administrative mergers did not change the cultures of the various health organisations.
57) Reputation	– Not assessed.
58) Transcending domain perceptions	– Not assessed.
59) Trust	– Trusting relationships between providers and managers facilitated teamwork.

Table 8

Structural factors perceived as influencing the implementation of six dimensions of the Local Health Network for Older People.

Factors	Clinical dimension	Professional dimension	Organisational dimension	Systemic dimension	Functional dimension	Normative dimension
Government policy and funding support	+	+	+++	+++	+++	++
Managers and policy makers use of innovation		+	++	+++	++	++
Characteristics of the population		+	+
Geographical setting (urban zones vs rural zones)		+	+