Doctoral thesis (Dissertations and theses)
Intégration de soins: du patient à une population
Belche, Jean Luc
2016
 

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Keywords :
integration of care; primary care; secondary care; general practitioner; local health system
Abstract :
[en] Through our experience of general practice we noticed a lack of coordination between the general practitioner and the hospital that could lead to poor quality patient care. We decided, therefore, to focus upon the integration between levels of care as our main research topic. Problem setting Clarifying concepts such as ‘levels of care’ (Chapter 1) and integration of care’ (Chapter 2) was the first step of our work. The concept of ‘levels of care’ is entwined with ‘integration of care’. The historic differentiation between concept of ‘levels of care’ is not only a consequence of the medical specialization process, but also a result of the drive for greater efficiency in the delivery of patient care. In general the differentiation process is a response to complex situation and consecutive integration is necessary to maintain coherent and global action. An in-depth analysis of these two concepts gave us a theoretical framework for our analysis. We explained the distinction between ‘primary health care’ and ‘primary care’ to avoid confusion that might occur when these terms are used. We chose a definition of levels of care based on the work of Barbara Starfield: the first level of care, or ‘primary care’, represents the first access to health care, and is responsible for coordination, comprehensiveness and continuity of care; the second level of care, or ‘secondary care’, performs a support function, of the scientific, technological and logistical aspects. Throughout this work we considered integration of care as a continuous process of variable intensity depending upon the complexity of the care situation. We therefore established a series of supporting tools to integration of care according to this continuum. Additionally, in order to address the different ways to approach integrated care, we chose the Rainbow Model of Integrated Care (RMIC) as a conceptual framework. The RMIC proposes a logical hierarchy of the key dimensions of integrated care, suitable for our research and analysis. Within these theoretical frameworks, we formulated several research questions that address the integration between levels of care: How are the professional and organizational dimensions of integrated care practically developed in the Belgian health care system, at the national and local level? What are the conditions for implementation of a model of integrated care of the two levels of care in a local context? What is the impact of such a model in terms of integration of care? Professional dimension of integration between the levels of care The analysis of the professional dimension of integration of care consisted of two complementary activities. First, we identified the main tools and mechanisms that support integration of care between the general practitioner and medical specialist within the hospital (Chapter 3). We completed our analysis with the findings of several studies on the integration process between those professionals in different care situations, such as treatment management between hospitalisation and discharge of chronic care for HIV patients, cancer patients or obese patients after bariatric surgery (Chapter 4). From this analysis, we confirmed the state of fragmentation between levels of care within the healthcare system. On the professional side, we faced weaknesses on the normative and functional dimension of integration of care. There is a tendency of the secondary care to appropriate the primary care functions, without real consultation and with the risk of gaps in the patient’s care (e.g. preventive care and psycho-social care). Task clarification between professionals of both levels of care occurs too often in the restricted scope of one disease. In this context of unclear role assignment, each professional only relies on his own informal professional network built on interpersonal relationships. Some recent evolutions that may improve integration between professionals have been noticed, such as computerized medical information transfer that may facilitate communication between levels of care. However, the poor structure of primary care, still characterized by solo practice and weak structural links with care coordination function, could represent a barrier to improved professional integration. These findings allow us to acknowledge the added value of Barbara Starfield’s functional conception of levels of care to develop the professional relationships between the general practitioners and medical specialists in the hospital. It also became obvious that we had to complete our analysis at the organizational level, as the professionals frequently mentioned the organizational framework as a barrier. Organizational dimension of integration between levels of care The same analysis process was developed for the organizational dimension of integration between levels of care : identification of existing structures (Chapter 5) and empirical evaluation with a participatory action research (PAR) (Chapter 6). Primary care is fragmented and poorly organized while the hospital is a highly structured and multidisciplinary organization. For general practice in particular, in Belgium, local GP’s organizations, GP’s circles, are asked to play a key role in local health policies but have limited resources, considering governance and leadership. Moreover, existing networks of health organizations covering large areas fail to take local specificities of the health system into account. In this context the participatory action research SYLOS has started in some urban settings in Belgium (Chapter 6). The aim was to organize integration between levels of care at the local level, using a recognised model built on a functional conception of levels of care. The Local Health System model, used in this PAR, is a decentralized and functional unit of the health care system at the local level. It integrates activities of health care services in order to provide primary health care to a determined population. This unit is galvanised and coordinated by a steering group. We followed Grodos & Mercenier’s methodology of participative action research that is recognized on the field of health system research. Our hypothesis was as follows: organizational representatives, initially from hospital and one GPs’ circle, and researchers as moderators, could be the steering group implementing and coordinating local integrated activities. We considered various urban settings, including one with several hospitals. The dynamic of integration initiated by some researchers and hospital and GP’s representatives extended rapidly: other local primary care organizations and hospitals were included This process recreated the complexity of local health system in an urban setting with a multidisciplinary primary care and a multi-hospital secondary care. We still identified reluctance of the actors to include other organizations during the process. This may be explained by the isolation of the medical profession among other caregivers and the market-based organization of secondary care in Belgium. This research allowed us to draw two different models of care territories involved in professional and organizational integration of care. The moderator’s function, detached from both primary and secondary care, was essential during the process. It has been defined during the research action: it requires specific competencies of coordination, group dynamics and technical support to integration of levels of care. This function also compensated structural weakness of primary care in our context. Temporal sequence of activities, observed during this action research, demonstrated the dynamic of the various dimensions of integration of care. It also increased our knowledge of the RMIC. Two of the explored local context in the PAR did not succeed into implementing a steering group. However, it brought useful information concerning motivation and necessary leadership. We also showed that the dynamics of this action research is the result of top-down policies (promoting collaboration of the hospital with other partners and structuring primary care) and bottom-up local initiatives, such as participative action research, acting synergistically. Conclusion The knowledge of professional and organizational integration of levels of care, obtained through this analysis, can directly influence professional practice, professionals’ training and health system organization. If differentiation is an answer to complexity of care, integration between levels of care is necessary and has to be built on strong bedrock composed by common conceptual framework, reciprocal knowledge and recognition of professionals and organizations’ complementarity and synergy. On this basis, implementation of supporting tools and mechanisms for integration of care should be facilitated. The added value of a coordination structure, for the organizational dimension of integration of care at the local level, should also be considered in the Belgian health system.
Disciplines :
General & internal medicine
Author, co-author :
Belche, Jean Luc  ;  Université de Liège - ULiège > Département des sciences cliniques > Médecine générale
Language :
French
Title :
Intégration de soins: du patient à une population
Alternative titles :
[en] Integrated care: from a patient to a population
Defense date :
15 September 2016
Number of pages :
460
Institution :
ULiège - Université de Liège
Degree :
Docteur en sciences médicales
Promotor :
Giet, Didier ;  Université de Liège - ULiège > Soins primaires et santé
President :
Vanmeerbeek, Marc  ;  Université de Liège - ULiège > Département des sciences cliniques
Jury member :
Albert, Adelin  ;  Université de Liège - ULiège > Département des sciences de la santé publique
Unger, Pierre
Philips, Hilde
GILLET, Pierre ;  Centre Hospitalier Universitaire de Liège - CHU > Direction médicale
Godderis, Geert
Saint-Lary, Olivier
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since 03 November 2018

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