Better care for patients with complex needs



Approximately 10% of the population generate 80% of health care costs! These heavy health services users seek emergency care or are hospitalized several times a year for their complex conditions that often involve chronic and mental illness and socioeconomic insecurity in a system that is poorly adapted to their reality. These patients require services that are highly coordinated between health care, social services and community network professionals, who, all too often, still work in silos. In response, two researchers in Sherbrooke and Chicoutimi undertook a project to support and assess the case management programs of the Centre intégré universitaire de santé et de services sociaux (CIUSSS) in Saguenay–Lac-Saint-Jean.

Patients say they have better access to different types of care and appreciate being involved in the management of their own health.

A nurse or social worker manages each case, taking charge of the patient and his/her medical follow-ups. This type of intervention, which is more common in the geriatrics and mental health sectors, seems promising for adults who struggle with complex health problems. Since 2014, with a particular view to understand the most promising approaches and inform the reflection by the Ministère de la Santé et des Services sociaux on the issue, Catherine Hudon, family physician and professor in the department of family medicine at Université de Sherbrooke, Maud-Christine Chouinard, nurse and professor in the department of health sciences at UQAC and their case management partners at the CIUSSS in Saguenay-Lac-Saint-Jean have been collaborating on the V1SAGES 2 project.

Through interviews, group discussions, surveys and observations, they identified key elements, including the significant importance of determining which patients have complex needs and considering family medicine groups as critical case management partners. Patients say they have better access to different types of care and appreciate being involved in the management of their own health. All for one has never been more true!