Abstract
Introduction: Implementation of integrated care pathways is viewed as an answer to the problem of fragmentation of care. This organization appeared in the USA and then in UK in the mid-1980s. Based on time-limited episodes of care, it aims to coordinate all care and services on the ground of evidence and with the support of multidisciplinary teams. In Quebec, a health system reform (2015) put the implementation of such pathways at the agenda. Their approach integrates social and health dimensions, is user-centered, and proposes an intertwining of several episodes of care and services over long periods with an intersectoral perspective.
Methods: We conducted a developmental evaluation to study the implementation of integrated care pathways in 3 healthcare organizations and their network in Quebec (2017-2019). In this study we describe the development of the integrated care pathways and analyze the process of governance innovation. We seek to understand how change in governance occurred and its impact of leadership and decision taking inside and outside through healthcare organizations. The analysis used a conceptual framework based on the Complex Adaptive Systems (CAS) approach of multi-level governance. Qualitative empirical data were collected through documentation (N=40), observation (N=175h), and semi-structured interviews with key informants (N=21).
Results : Our results provide a detailed documentation of the practices put in place by implementers and the impacts of feedback on the adaptation processes inside health organizations and outside: in the community and intersectoral networks. Implementation of health and social pathways is based on a double innovation in terms of governance and organization of services, leaving room for potential tensions with more traditional types of management that are also in place. These tensions are necessary in allowing these vertical and horizontal interdependencies to be questioned. But they can slow down the institutionalization of this governance innovation based on intersectoral partnership and transversality.
The notions of territories emerge when it comes to meeting the needs of populations with equity. The distribution of leadership is more and more local and collaborative to take decisions closer to the action.
Conclusion: This study highlights that dynamic collaborative processes and design-in-action require both dedicated governance spaces to design and implement an innovation and time to align and adapt this innovation appropriately to its context. Otherwise, some misunderstandings and inconsistencies are conveyed and questions about the sustainability of the innovation arise.
Implications: Our results will be of interest for health care decision makers aiming to better respond to the needs of users and to increase their participation at all levels of organization and networks. These results are the basis for a provincial scale-up project currently underway and considering the current COVID-19 crisis.
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