- Change management support
- From planning the desired change to selecting the care pathway and reviewing publications, to implementing change and a continuous improvement process
- Support for knowledge synthesis and transfer
- Implementation consulting and support for:
- literature search in electronic databases and/or grey literature
- Cochrane systematic review or quick review
- meta-analysis of intervention, diagnostic, observational or meta-analysis studies in the network
- knowledge transfer plans
- deliberative knowledge transfer workshops
- involving decision-makers in POR
- Implementation consulting and support for:
- Support for implementing information monitoring on a given subject
- Support for conducting a literature review
- Support for designing tools to help decision-making
- Support in the use of tools:
- ATCER (assigns a probability that publications are scientific studies)
- CATeval (facilitates study quality appraisal)
- eSRAP (collaborative information monitoring platform)
- Training and communities of practice on the ESPACE PROXIMITÉ platform
What is an LHS?
A learning health system helps us put science into our practices. It helps us measure, analyze, apply, and then repeat the cycle. From practices to data, from data to knowledge, from knowledge to clinical and organizational practices.
For a health system to continuously improve, it must continuously repeat the learning cycle.
The demonstration project: an example of a learning health system
Project: Improve the ability to identify patients at risk of becoming frequent users of emergency services.
Begun in 2016, in support of the V1SAGES program, this flagship project helped demonstrate the value and benefits of the learning health system (LHS) approach. Led by an interprofessional team involving patients and their loved ones, it embodied a research continuum, from structured data collection and expansion of its use, to producing tools to support decision-making and, ultimately, integrating the knowledge acquired into clinical and organizational practices.
Three streams and objectives
- Improve the ability to identify patients at risk of becoming frequent users of emergency services
- Further integrate the social and community streams with the health stream
- Identify the decision-making issues for frequent users of services with complex needs
- Multidisciplinary and interprofessional team
- Active involvement of six patient partners in all phases of the project
- Support for most resources in the Unité de soutien SRAP du Québec
- Systematic review, collection of data on decision-making needs and methods to integrate health care and social streams
- Developing and validating clinical tools
- Developing the toolCONECT-6 for identifying individuals at risk of becoming frequent users of emergency services, and implementing it in the clinical setting
- Improving training for clinical staff
- Optimizing nurses’ role in monitoring patients with complex needs at risk of becoming frequent users of emergency services
As part of the demonstration project, we provided POR capacity-building support to six patient partners, three researchers, six professional research staff members and ten members of the student community.
To this day, all of these people work in the POR field. This had a leverage effect, as several of them subsequently received training or career grants and substantial funding, including:
- A $4M grant over four years to implement case management intervention similar to the V1SAGES program model in ten primary care clinics in five Canadian provinces
- A $575K grant from the MSSS’s Programme ciblé d’octrois de subventions, in partnership with the Unit and the FRQ-S
- Continuation of the demonstration project. The team is developing an online training series for clinical teams. In addition, they are aiming to scale the V1SAGES approach at other clinical institutions in Quebec.
- Learning resulting from a multicentric study: a new article by Marie-Ève Poitras and her team as part of the Unité de soutien SRAP du Québec demonstration project
- New shared decision-making tool for frequent users of health care services and their care teams
- CONECT-6: the first screening tool to rapidly identify patients suffering from chronic disease with complex health needs
Julie Godbout, Nurse, V1SAGES team case manager
Being a case manager has radically changed my relationship with clients. I used to see myself a bit like a teacher who provided knowledge to patients who just had to follow my advice and recommendations, because it was the right thing to do to be healthy! […] Now, I see myself as a resource, partner and coach.
Of course we have knowledge to pass on to patients, but they are ultimately responsible for making decisions about their lives and health. […] The case manager is there to support them, offer services, help them make decisions and navigate the health care system. They allow for a more thorough assessment of the individual’s needs.
Case management has also allowed me to develop relationships with other professionals and community resources, to better understand their roles and when and how to contact them when needed.
[…] Now when they have a patient with complex needs or a difficult situation, their instinct is to talk to other professionals. A co-development group was even set up to provide a forum to discuss these situations. Concrete solutions and concerted actions have emerged. Now that I’m replacing people in other fields, I miss these meetings.
Demande de service
Faire une demande de soutien à l’Unité de soutien SSA du Québec, c’est prendre part à l’émergence d’un système de santé apprenant (SSA). Nous proposons trois types de soutien : des formations, de la consultation et des outils.
Abonnez-vous! Une référence en système de santé apprenant (SSA) au Québec.