Implementing hierarchized care: A case study

Quebec’s Mental Health Action (MHAP) 2005-2010 proposes a reorganization of mental health services based on hierarchized care. This hierarchization consists of defining the care provided and the clients served by different service providers, as well as the interface management mechanisms between levels of care. Its objective is to improve the efficiency of the care system through better complementarity between service providers and by ensuring an increased continuity of care between them.

The MHAP’s model is similar to stepped care models found in scientific literature. Implementing this type of model could be complex, as it would require a restructuring of the existing service organization, and a collaboration between actors who are not accustomed working together. Using frameworks in this context may help prevent pitfalls inherent with implementing this type of change.

As part of my Master’s thesis[1], I carried out a case study in a Montréal CSSS using two frameworks that helped analyze the implementation of hierarchized care in this territory.

Firstly, the hierarchized care model currently in place was compared to stepped care models found in scientific literature and presented similarities on several points. For example, the implemented model is based on a populational approach; presents a continuum of services; and explains the care offered by the different service providers. However, intervention methods are proposed in the general sense for mental disorders as opposed to specific disorders, and hierarchization within the continuum is not available. Although the implemented model includes criteria to facilitate the guidance of clients, there is no objective tool to evaluate them or to perform a systematic follow-up of treatment outcomes.

Secondly, contextual and organizational factors facilitating or impeding the implementation of hierarchized care were analyzed using the Champagne[2] model. Among these, several facilitating factors were present such as positive perceptions toward the implemented model, cooperation and collective leadership among institutions, and the creation of collective learning environments for discussing and experimenting with the hierarchized care model. Certain elements should be considered, however, to ensure a successful long-term implementation, namely standardizing reference criteria and mechanisms, clarifying the role of guichets d’accès (centralized access points), and integrating general practitioners in the hierarchized care model.

Successful implementation of hierarchized care rests on clinical and organizational factors. As a result, this case study demonstrated that frameworks could be invaluable in supporting or analyzing the implementation of hierarchized care on a given territory.

[1] Wilson, Véronique (2011). Facteurs contextuels influençant l’implantation d’un modèle de hiérarchisation des soins en santé mentale : une étude de cas en milieu montréalais. Mémoire de maîtrise. Université de Montréal.

[2] Champagne, François (2002). La capacité de gérer le changement dans les organisations de santé. Commission sur l’avenir des soins de santé au Canada. Étude no 39.