Abstract
Background: Eighteen percent of people in primary healthcare face interacting challenges among the physical, mental, and social dimensions of health, experiencing the most complex needs, and resulting in decreased quality of life as well as increased disability and mortality risk. The organization of services for this population calls for integrated care. 2. Objective: To report on the development and evaluation of the V1SAGES Approach over the last decade which aims to improve integrated care for adults with complex needs who frequently use healthcare services around their life project; and to present the V1SAGES Approach toolkit. 3. Study Designs: The Approach was developed and evaluated through many projects using various study designs: 1) literature reviews (scoping, systematic, and realist); 2) qualitative studies; 3) case studies; 4) randomized controlled trial; 5) logic model and analysis; and 6) validation of a case-finding tool aiming to identify adults with complex needs. 4. Participatory approach: All of these projects involved stakeholders (patient partners, clinicians, and decision-makers), patient partners playing a major role in their development and governance. The governance structure and strategies for patient partners involvement will be presented. 5. Intervention: Case managers in hospitals and care navigators in primary care clinics work with the person and their family to identify, evaluate, plan, and coordinate services in close collaboration with providers at all levels of healthcare and community organizations. Its standard of care proposes to: 1) identify adults with complex needs who frequently use healthcare services; 2) assess their needs, life project, and preferences; 3) develop an individualized services plan (ISP) with the person and relevant partners during an in-person or virtual meeting; 4) coordinate care focusing on the person’s and their family’s needs among all interdisciplinary and multisectoral partners; 5) offer self-management support and education to the person and their family. The toolkit includes web-based modules to train case managers and care navigators, a standard of care, the CONECT-6 case-finding tool, and other clinical tools. 6. Results: Our studies documented positive impacts of the Approach on individuals, healthcare providers, and health systems. A mixed method study with randomized controlled trial documented a reduction of psychological distress and an improved sense of security. A qualitative study reported people’s positive experience of care integration. A logic model and a program theory were developed to explain how and why the Approach works and concluded that a trusting patient-clinician relationship and the engagement of patients and clinicians are key for impact. 7. Learnings: The evidence-based V1SAGES Approach and toolkit could be useful to international researchers, clinicians, patient partners, and decision-makers engaged in improving health of people with complex needs and their experience of integrated care. This Approach could also improve the healthcare system’s efficiency and reduce its economic burden. Lessons learned will be shared about governance, communication plans, information systems, standardized tools, capacity development, and continuous improvement. 8. Next steps: Realist evaluations are under way to evaluate the process of external facilitation when implementing the V1SAGES Approach and to evaluate its scale-up at larger scale.