"CLSC du futur" project: home support and telecare

Prepared by: Jean-Paul Fortin, Lise Lamothe, Françoise Labbé, Julie Duplantie, Djamel Messikh, Daniel Douillard, and Céline Lepage
2005
Canada health infostructure partnerships program (CHIPP)

Synopsis

The purpose of the "CLSC du futur" project was to consolidate and, ultimately, disseminate a model of health service integration in which services are provided in conjunction with a network of partners within a given territory and supported by new information and communication technologies (NICTs). The ultimate goal of the consolidation being to provide an optimum care continuum to clients of the home support program. An evaluation process, described as comprehensive, pluralistic and educational (coaching), was carried out throughout the project.

The project's main challenge was to create an integrated service network out of services already available in the community, based on "territorial"-as opposed to "institutional"-logic. The informational challenge consisted of ensuring that the nucleus around which information gravitates is the client rather than the site where services are delivered. Central to the activities of the "CLSC du futur" is an effective and efficient partnership, which ensures that information is made available at the location where the client-worker care episode takes place. Accordingly, the success of the project is to be measured by its ability to strengthen the functional links between frontline services, medical clinics and specialized services, and by the implementation of technologies that make it possible to convey information in real time. Carrying out a project of this kind also raises the challenge of fostering ownership of technological solutions and new practices by managers and workers involved in the delivery of health care.

Two types of technology have been tested as a means of supporting service integration: the home support information system-the cornerstone of which is the electronic clinical record-and telecare. Despite their dissimilarities, both systems can contribute to the development of a health care delivery model based on a service logic, as opposed to an institutional logic. Both of these clinically oriented technologies will strengthen the integrated service network even further if they are incorporated into administrative applications, as well as the health sector's telecommunications network, as part of a comprehensive solution.

This project is more revolutionary than it might seem at first glance. Indeed, moving toward a service logic constitutes a paradigm shift, since it requires a redefinition of the organizational nucleus (the health care continuum). The challenge of this reorganization consists of rethinking the ways in which health care services are delivered-in order to integrate clinical activities in a context where organizational boundaries are becoming less clearly defined-as well as coordinating clinical imperatives (micro-organizational level) with systemic imperatives (macro-organizational level). The result of these efforts is a system in which health services are organized on a "production flow" basis. These are complex changes that require creativity (Lamothe, 2002).

Home support information system

The home support information system comprises computerized and digitized clinical records, worker agenda management capabilities, on-line referral management capabilities, and telecommunications tools. The purpose of this solution is to make workers more mobile, which is to say less present at the CLSC, thus reducing accommodation requirements. The ultimate goal of this approach is to address the needs of the many different practice settings and NICT-use contexts that characterize homecare. More to the point, homecare requires an interoperable solution, or multiple solutions, to respond to its diverse clienteles, practices, and user environments. These solutions must also be integrated, responsive, efficient, robust, as well as acceptable to and accepted by users.

Following its progressive adoption by the workers, the information system generated change within the organization and in workers' practices, despite numerous organizational and logistical constraints. Workers appreciate the system's many advantages, particularly the electronic clinical record, which provides access to comprehensive patient information in real time. It should be noted that the development of this solution required in-depth knowledge of clinical and administrative processes-knowledge acquired through ongoing interaction with these processes.

Telecare

The telecare component was carried out at three locations: the CLSC Orléans in Quebec City and in urban and rural Manitoba. The target clientele was composed of chronically ill patients (COLD, heart failure). The telecare trial provided an opportunity to emphasize prevention and early intervention with these patients, known for their frequent visits to emergency rooms. By paying closer attention to the perceptions of workers and their clients, a number of emergency room visits and hospitalizations were avoided.

The choice of equipment for the "CLSC du futur" project was based on the clinical and physical characteristics of the target clientele. It was determined that this equipment might not be suitable for other clienteles and this hypothesis should provide greater insight into issues related to the choice of clienteles and the characteristics of telecare equipment.

In addition to bringing more attention to bear on a clientele too often neglected by home support services, the telecare trials brought to light two models of homecare service organization. In the case of the CLSC Orléans, a specialized approach emerged, whereas in Manitoba, a more multi-purpose approach came to the fore. The introduction of a "user logic" creates at least two challenges for managers and workers within the organization. On the one hand, it requires a work organization model that allows for rapid response to users' needs and calls for assistance, as opposed to a system in which services are organized on the basis of predetermined intervention plans. On the other hand, it is important to ensure that both work organization models are coordinated on a functional level. Neither model is more appropriate in principal and the fundamental challenge for the organization is to maintain a functional balance between the two. Much thought will need to go into these issues.

Finally, it would appear that telecare has had a positive impact on both users and health professionals. Patients were more satisfied with the care and services they received, while workers improved their practices (greater ease of diagnosis, better patient follow up, prevention and early intervention). Also highly important is the creation of a relationship of trust between the individuals involved, as well as the presence of a key worker to ensure effective communication. At the CLSC Orléans, this resulted in improved communication, cooperation and coordination between front-line services and specialized services.

The solution implemented

The challenges inherent in integrating the various components of a technological system relate to issues of intellectual property, security, consent, shared assets, public-public and public-private partnership, and monitoring; in other words there are technological, organizational and professional challenges to be met. Also omnipresent are challenges linked to the management of shared assets within a common technological environment, as well as the need to provide support and technical maintenance services that are appropriate and, above all, adapted to the constraints commonly found in clinical settings.

From a technical standpoint, the project brings to light fundamental differences between the development of specific applications and the development of comprehensive, integrated solutions. The latter requires a far greater degree of interaction and coordination between trial sites and regional and central decision-makers.

Moreover, since this is a horizontal trial project, the integration of innovation into organizational practices is particularly important. However, this integration has scarcely begun. Had it been taken further, it would have reduced the inconveniences associated with a low level of involvement in the trial project from managers and personnel. It is important to note that, with an innovative project of this kind, two forms of management are required: management of the project itself, and management of a major organizational change. The presence of clinical leaders is crucial to the successful implementation of such change.

In short, computerization must be approached with a global vision that incorporates various dimensions, including professional practices, service organization and technology. Development and implementation strategies must take into account the nature of the project, as well as stakeholder dynamics.

Lessons learned

Based on the observations derived from the "CLSC du futur" project, four important factors need to be taken into account. Firstly, networked management of the various care and service continuums requires the involvement of a wide range of professionals, and gives rise to a variety of challenges which are likely to evolve depending on circumstances, as well as over time. Secondly, the variety and complexity of clinical conditions to be addressed exert a strong influence over the information requirements of professionals. Thirdly, NICTs must be adapted to meet the requirements of the highly varied practice settings and conditions in which professionals work; at the same time, the introduction of NICTs also requires professionals to modify their practices. Fourthly, changes in professional practices can have repercussions on organizational practices and raise a number of management issues. Consequently, it is important to take into account the needs of users, as well as those of workers and managers, in the very settings and conditions in which they practice, since the latter will need to share information, as well as modify their activities. These consequences can be anticipated and managed; they can also have a determining influence on the adoption of NICTs.

Given the uncertainty inherent in selecting and implementing appropriate solutions, the interactive approach seems preferable to a centralized, planned approach; the former fosters learning, while the latter can result in proposals that are poorly suited to local imperatives. The learning generated by the first approach may also be more conducive to the effective targeting of investments.

In order to ensure that decisions are better coordinated, it is also important to put in place, at the earliest stages of the implementation process, a framework that will govern interaction between local decision-makers and those at other levels. Discontinuities in the evolution of a project can hinder the mobilization of local stakeholders and impede the achievement of the objective of strengthening local health service networks.

Evaluation and knowledge sharing

As stated earlier, an evaluation process, described as comprehensive, pluralistic and educational, was carried out throughout the project. This contributed to the project's advancement, and made it possible to gather information from which many useful lessons concerning the project's sustainability and potential dissemination were derived. These lessons include:

• The importance of having a vision, strategic orientations, and a framework that incorporate the organizational components of health and social services, but also allow for territorial adjustments;
• Testing, deployment within the organization, and dissemination in other organizational contexts are three essential and complementary phases of the computerization process;
• A network of multidisciplinary experts specialized not only in the services in question, but also in the development, implementation and (formative) evaluation of large-scale computerization projects, and having the requisite critical distance, needs to be in place to support teams at the local and regional levels.

Finally, in the current Quebec context of health and social service reform, the scope of the challenges at issue argue in favour of providing ongoing support throughout the test and implementation phases. With innovation projects of this kind, researcher support goes hand in hand with evaluation. By sharing the knowledge generated through projects such as the "CLSC du futur," we can create an effective cooperative network that brings together the various strategic players involved in the delivery of health and social services in Quebec.

Please note that the synthesis report, the complete project evaluation report, as well as the report of project director Madeleine Chevrier, can be found on the CEFRIO Web site.