Better Care for Frequent Users Improves Quality of Life and Saves Resources in the Laurentians

The Problem

Small group consuming a high proportion of resources
The Centre de santé et de services sociaux des Sommets (CSSS) in the Laurentians, Quebec, recognized that certain patients suffering from complex chronic conditions were frequently visiting emergency departments (EDs). In addition, these patients were using a disproportionate amount of local healthcare resources during a time of challenging budget constraints.

The Solution

Empower patients to take charge of their health
The project grew from the recognition that by better community evaluation and follow-up of this cohort of heavy users, their quality of life would improve and the region would save healthcare resources. The ultimate goal was to enable the patients to take charge of their health, and therefore, create a ‘chronically well’ population.

How the Project Worked

Identify the right clients, provide community support
France Laframboise together with her CFHI EXTRA mentor Jean Mireault and her EXTRA improvement team, set out to gather the evidence that could lead to the creation of a local network focused on appropriate care and responsibility for the health of its population. By using an integrated clinical database that stratifies patients based on their use of health services, the CSSS was able to accurately identify the 200 highest users of emergency and hospital care. Surprisingly, they were relatively young clients, most of whom suffered from more than one chronic health condition, including mental disorders and problems with substance abuse.  

Recognizing that 93 percent of the patients had a family doctor, Laframboise and her team initially reached out to these individuals by sending a letter to every family doctor in the community. The letter explained that the CSSS had identified their patient as clinically complex and a high user of care and went on to ask for their support in improving their patient’s health status and well-being. The community nurse case managers then completed clinical assessments of the patients, revisited their preferences and, with the patients’ collaboration, coordinated plans for each one of them. In doing so, they enabled family members, neighbours, local pharmacists and family physicians to help these patients manage their health.

The improvement team actively followed the cohort for several months before transferring them to a ‘more traditional’ set-up of care. The team personally engaged each individual and worked proactively to avoid preventable ED visits and hospital admissions. One key strategy was to redesign primary care in the community, in active collaboration with family physicians and community pharmacists.

“Bringing communities together to manage vulnerable individuals proactively is efficient for improving people’s lives. Even if it is challenging for the system to create a chronically well population, the results speak for themselves. Patients, families, care givers and the care delivery system-at-large are all benefitting.”
– France Laframboise, Director of nursing and quality of care, CSSS des Sommets (2004 to 2009)

The Impact

Dramatic decrease in resource use and increase in appropriate care 
The program has been successful at several levels. In its first two years (for those 200 patients), the number of ED visits dropped by 72 percent (from 760 to 212), hospital admissions by 83 percent (from 514 to 88) and inpatient days by 80 percent (from 4,298 to 852) which is equivalent to a decrease of 9.4 percent of total hospital bed occupancy.  In addition, questionnaire responses showed that well-being and quality of life had improved for the patients. Meanwhile, the community reported that the creation of new alliances had led to more effective use of community resources.

Since the official conclusion of the project in 2008, the CSSS has realized many further improvements. Careful tracking of the 200 patients has revealed a 50 to 60 percent reduction in either ED visits or hospital admissions, and the occupancy rate of short-term care medical beds decreased by 10 percent. Other healthcare organizations have taken note. A CFHI EXTRA improvement team in Saguenay-Lac St. Jean, Quebec has since tailored its own project to address comparable issues in their region.

Lessons Learned

Do not reinvent the wheel
Laframboise cautions others implementing complex improvements not to invent anything but to learn and adapt what has proven effective in the literature. “Many people have gone before you. For a project of this nature, you should be able to find the tools and the evidence you need to succeed.” Her team benefitted from similar integrated approaches, including one from the National Health Service in the United Kingdom.

Ensure Buy-in at Senior Levels
Senior managers and decision makers (such as a hospital’s Board and CEO) must have a profound belief in the work for such a program to succeed – and not just because the improvement team needs their nod of approval. As Laframboise learned, success depends in part on using integrated clinical data and asking and answering difficult questions about how the system can be improved for better population health. “All of these patients are a little bit of proof that the system could have been doing better. The decision makers need to be open in learning to use and analyze data and be willing to have the challenging discussions.”

Laframboise urges other healthcare teams pursuing similar projects to keep peoples’ health front and centre. “By bringing partners together and managing these vulnerable individuals proactively in the community, we can help ensure that they have a better quality of life (or end-of life) with their families, outside the intensive care and the emergency department.”

Why it matters to Canadians

Focusing on people improves population health
As Laframboise says, her team’s greatest motive was to improve the health of the vulnerable people in the community. She maintains that the focus on people rather than resources is the project’s most important legacy. “If we had engaged in this type of transformation only for financial reasons, we might have lost sight of its real intention to make a positive difference in people’s lives.” Her project has shown that, once the positive difference has been accomplished, local emergency departments are less busy, physicians believe in the system and financial rewards follow.

France Laframboise,
Expert in chronic disease prevention and management
CFHI Improvement Coach and Guest Faculty, Atlantic Healthcare Collaboration


To learn more about this project or the EXTRA program, visit