Adoption of an integrated model for the dynamic management of chronic illness

Agence de la santé et des services sociaux du Saguenay-Lac-St-Jean, Centre de santé et des services sociaux du Cléophas-Claveau et Centre de santé et des services sociaux de Lac-St-Jean (QC)

The Challenge

The importance of taking chronic disease management into consideration in our healthcare systems. A revamping of care processes is essential. 

The Improvement Project

The proposed improvement project has two main goals: improving the population’s state of health, and cost control. 

The regional studies carried out show, as does scientific knowledge, that a limited number of users make frequent use of clinical services, specifically emergency, hospital beds and the community health clinic (CLSC). In the region, despite a high proportion of patients with a family physician, and broad walk-in coverage to avoid emergency, two patients out of ten effectively visit emergency. Moreover, data show that as little as 5% of the population in a given area accounts for 50% of the consumption of hospital beds. This situation reflects the piecemeal nature of our clinical administration.

The intervention project consists in actively reconfiguring clinical activities and administration between the health and social service centres and the local health networks, and in eliciting the participation of the region’s network of clinics.

The Impact 

The expected outcomes will depend to a great extent on the coordination of efforts between the second and first lines of care, especially regarding the management of large consumers of care and patients with chronic diseases. We hope to be able to develop a funding rationale through better knowledge of this clientele.