Multicentric Evaluation of the Impact of a Multi-disciplinary, Systematic Follow-up Model: From the Hospital to the Community 

Main Messages

Many criteria must be taken into account for the successful implementation of an innovation such as a systematic follow-up model:

  • Evaluate the possibility of implementing such an innovation; consider factors such as contributions of financial and human support.
  • The innovation must be carried out by individuals who are competent, credible and committed. It must also promote participation by all the target players, right from the planning phase.
  • Take the needs of the parties involved into account, and make sure that they all share a common vision of the project.
  • Select the tool based on the realities of the environment and make plans for training as well as organized support. In case of innovations derived from models that are already designed or up and running in other environments, it is important that they be adaptable to suit what the players consider to be appropriate for their practice.
  • The innovation must enhance the value of scientific knowledge through best practices, as well as the clinical knowledge that has been gained and general knowledge of the context and the organizational culture.
  • Take the time that is needed to adopt and apply the innovation.

Significant consequences of the introduction of systematic patient follow-up and home support:

  • It has enabled the nurses to organize their practice and thereby reduce variations between practitioners.
  • By developing new areas of expertise, this innovation provides an opportunity for practitioners to become familiar with, and to assume, new professional roles.
  • The application of this innovation has not produced any significant effect on home follow-up of patients or on the volume of services required. However, it has had positive impacts on the development of new, evidence-informed clinical practices, on a feeling of security on the part of junior nurses, and on the harmonization of clinical practices.


The situation of amalgamations of healthcare institutions has raised concerns in clinical environments about setting shared clinical objectives, standardizing practices and improving the continuity of patient care, among other things. With this in mind, some local community service centres (CLSCs) in the Québec City area have adopted and implemented a model of systematic home follow-up of patients. This research evaluates the process of implementing this systematic follow-up model within professional practices, and examines the impact of such an innovation on the patients.

This quasi-experimental research was conducted in collaboration with three CLSCs in the Québec City area: two had adopted systematic patient follow-up in their environment, and one had not been exposed to this model of practice. The model of patient follow-up that was used included clinical paths used with patients who had been hospitalized for heart surgery. To understand the factors that were taken into account in the adoption of systematic patient follow-up, and to pinpoint the factors that made its application easier or more difficult, individual and group interviews were conducted with nurses, managers and caregivers who were closely or indirectly involved in the delivery and management of the services provided under the follow-up program. The information gathered was analyzed according to the first four Paillé phases1. In addition, the effects of follow-up on the patients were evaluated with respect to certain aspects of their health (quality of life, functional autonomy and the existence of depression-related factors) as well as their satisfaction with the services received, and in relation to their use of healthcare services.

In general, the introduction of systematic home follow-up enabled the nurses to better organize their practice and to reduce inter-practitioner variations in the context of amalgamations of healthcare institutions. For the participating practitioners, it also provided an opportunity to become familiar with, and to assume, new professional roles. Finally, although it did not have any significant impact on home follow-up of the target clientele, this innovation did have positive effects in that it helped the nurses who had little experience with home-based care to feel more secure, and promoted the harmonizing of clinical practices.

Certain criteria are key to successfully implementing and applying an innovation such as systematic patient follow-up. First, the project must be spearheaded by individuals who are competent, credible and committed. At the same time, it must promote participation by all the target players right from the planning stage, while ensuring that the project meets their needs. The tool must be chosen based on the realities of the environment. It must also enhance the value of the clinical knowledge that has been gained, along with more general knowledge of the context and the organizational culture. Finally, in order for the exercise to unfold harmoniously, all the players who are engaged in the process must take the time that is needed to implement and apply the innovation,

Studies on systematic patient follow-up in the context of home follow-up are few and far between. Additional research is needed to evaluate its effects, but this time it should encompass pathologies or health problems that are chronic or that entail a loss of autonomy.