Assessment of the Integrated Network of Oncology Care and Services: the Montérégie Experience

by Daniele Roberge | Dec 01, 2004

Key Implications for Decision Makers

Analysis of the implementation process and effects of the Montérégie cancer network reveals the following lessons:

  • Developing co-operation between professionals and between independent organizations requires dedicated time and resources as well as an effort to raise awareness among the various partners so they understand their roles, responsibilities and the project's underlying vision.
  • To achieve the objectives of co-ordinating and integrating care, we must invest in development of appropriate instrumentation (such as upgrading players' skills, developing co-ordination tools).
  • Implementing a network requires the participation of a wide range of players who are scattered throughout various organizations and settings of practice. The need to gather these players around a joint project increases the investment required to raise awareness and provide training.
  • Leadership of a network should rest with the professionals who support it and who can maintain the vision of the network at the various steps of implementation. This leadership must be supported by the policy makers and adminstrators at different governance levels in the healthcare system.
  • The hospital can be a powerful driving force for developing a network. A special effort must be made, however, to ensure that the indispensable resources in the community or in private medical clinics are used.
  • The participation of doctors is critical, though it is difficult to obtain and represents an important challenge in all projects to develop networks. Besides adjusting remuneration methods, doctors' participation requires diverse and persistant strategies.
  • The development of networks organized by disease may prove more effective in channelling efforts to co-ordinate care. There is also the problem of ensuring "specialization" of staff in a context of scarce human resources and high demand for all care.
  • The volunteer-based approach relying on positive incentives for creating networks (investment of new resources, training, information) can produce beneficial results in terms of quality of care. The study's design did not look at longer-term benefits.
  • Although the interdisciplinary teams at the base of this network are locally established, a consistent approach in terms of policies for organizing care is necessary at the various intervention levels in the healthcare system (ministry, regional agencies).
  • The development and stability of a network depend on effective information systems to interconnect professionals, improve clinical activities, and support management. Similarly, the establishment of new organizational models should be accompanied by a formative evaluation process.
  • Adequately addressing the needs of a growing number of people coping with chronic conditions is a priority of the healthcare system. There is growing recognition of the complementarity of networks organized by disease and of primary care services for treating chronic conditions. The co-operation of networks organized by disease with primary care services should be a major issue for officials responsible for organizing healthcare services.
  • Local services networks now being developed in Quebec entail structuring factors to update deployment of networks organized by disease and to promote their articulation with primary care services. Their deployment is based on a management approach through the continuum of care that specifically advocates the practice of interdisciplinarity and reinforced integration of primary care (general practitioners, private practices) into this continuum. Experience has shown that it is easier to mobilize professionals around an integration project when they have an institutional foundation.

Executive Summary

The Programme québécois de lutte contre le cancer (Québec anti-cancer program) calls for the establishment in each region of Québec of an integrated service network for cancer patients and their relatives. The Montérégie region is the first in Québec to have formally initiated the implementation of such a network, which includes the establishment of a regional centre for excellence in oncology, the assignment of nurse navigators to hospital's oncology outpatient clinics in the region, and the development of interdisciplinary teams in these milieus. The establishment of the Montérégie network is part of a project to regionalize oncology services that has followed a sinuous path and created tension between the regional centre and other hospitals in the region. This study seeks to answer the following questions: What strategies have been adopted to implement the Montérégie Cancer Network? How and to what extent have these strategies led to integration at the local level? Which factors have fostered or hampered the emergence of the network and its effects?

A multiple case study approach was adopted. The cases (n=5) are hospitals in the region offering oncology services and their community partners. The period of observation covered by the study is approximately four years (1999-2003). The implementation analysis rests primarily upon qualitative material and an array of methods and data sources, including non-participant observations of committees (n=50) and semi-structured interviews (n=69). The analysis of effects relies on process indicators of outpatient clinic patient management by nurse navigators and multidisciplinary teams.

Key changes resulting from the implementation of the network

Hospitals in the region: Resistance to the Montérégie Cancer Network has diminished, trust in the regional centre was developed, and collaboration with it to foster access to specialized services was initiated.

Local teams: An environment of trust among professionals developed and the teams adopted tools and procedures to co-ordinate their actions. Nurses and psychosocial professionals, who are the most extensively involved in the project, are taking an interest in practice guidelines. Other professionals such as pharmacists and nutritionists recognize the benefits of co-operation and are showing an interest in teamwork.

Professional practice: Professional practices in hospital outpatient clinics appears to be shifting towards a range of services centred on patients' overall needs, one that fosters the empowerment, humanization, and continuity of care. The management of oncology emergencies has been improved in most hospitals. Efforts were made in a number of sub-regions to develop homecare chemotherapy and to enhance co-ordination of oncology patient-specific services between hospitals and CLSCs (local community service centres).

Facilitating factors

A context favourable to change: Strong clinical leaders and support from the Agence régionale (regional agency). Several convergent factors have spurred the network's emergence: (1) the project to regionalize oncology services; (2) strong, credible clinical leaders who acted as catalysts for collaboration in a context where specialized resources in oncology are limited and not all local hospitals saw the proposed network as a priority; and (3) financial support from the Agence régionale and its involvement in the network's governance.

Professionals as agents for change and mobilization and support strategies. Regional governance relied on professionals, the key actors, to initiate change. Various strategies, such as communications and the establishment of regional committees made up of professionals, were adopted to arouse individual interest in co-operating and to emphasize the added value of co-operation. These strategies contributed to the sharing of a common vision of the project and helped create trust among professionals. Emphasis was placed on upgrading the skills of oncology nurses and psychosocial professionals who work with cancer patients, through regional training programs, and on support and regular supervision for these professionals in their efforts to engage in interdisciplinary co-operation. At the local level, the support of administrators and measures adopted to foster interdisciplinary initiatives are important factors.

Limiting factors

Hospital governance. The decision at the outset to delegate to the regional hospital the mandate to implement the network implied that considerable emphasis was placed on the delivery of specialized clinical services. It led to confusion concerning the respective roles of the hospital and the Agence régionale in the network's development and in respect of each one's authority.

Limited openness to other partners in the network. The CLSCs were asked belatedly to participate in the governance of the Montérégie Cancer Network. Above all, they were asked to formalize co-ordination procedures governing the delivery of complementary clinical services in the hospital and to support the upgrading of their oncology nurses' technical skills. The role of primary care in the network is difficult to define in the context of scarce resources (oncologists and general practitioners) and the numerous healthcare reorganization projects to be implemented in the region.

Key actors with little input. It was thought that the assignment of nurse navigators would lead to all of the desired changes in the organizations. While such nurses brought a new philosophy of intervention into their respective milieus, they have neither the legitimacy nor the leverage to encourage other professionals to co-operate. In particular, they had to assert their legitimacy among oncologists who strongly opposed the Montérégie Cancer Network at the outset because they feared a concentration of expertise in the regional hospital and the shifting of patients to this establishment. This context certainly limited physicians' participation. Local administrators were called upon to a lesser extent to implement the Montérégie Cancer Network in their milieu, with the result that administrative support for the development of the teams was occasionally tentative.

Conclusion

The emergence of the integrated oncology service network in the Montérégie region is attributable to the simultaneous combination of several favourable conditions. Management relied on professionals to initiate change and on various strategies to foster the adoption of the new philosophy and support professionals in their efforts to co-operate. These strategies are appropriate considering the challenges posed by the implementation of an integration model that relies essentially on the determination of professionals and organizations to co-operate without administrative integration. This study confirms that the introduction of an integrated service network is a very long and complex process, since it requires the collaboration of actors at different levels of the healthcare system. To implement other components of the network, leaders will have to continue to rely on local dynamics and avoid the imposition of a single model.