Improving Our Response to the Unmet Health Needs of People with Complex Health Needs: A partnership between family medicine groups and the community
The COVID-19 Pandemic Response and Impact Grant (Co-RIG) Program: Phase II focuses on innovations and initiatives that prepare family physicians and their interprofessional teams to cope with challenges related to the pandemic and its long-term impact.
Dr. Catherine Hudon and her team, at the Université de Sherbrooke, Université de Montréal, and the Integrated Health and Social Services University Center of Nord-de-l’Île-Montréal, are working within communities that require complex responses to their unmet health needs. The goal of the project is to implement and evaluate case managers in four family medicine groups (FMGs), this new intervention now including telehealth modalities (developed in Co-RIG Phase I). With this project, the team aims to understand how the case managers :
1) influence the experiences of people with complex needs and professionals
2) impact care of people with complex needs
3) improve interaction with community-based resources
This project has great potential to improve access to, and the continuity of, services during the pandemic and to also improve collaboration between the FMGs, the community and the hospital networks in Montreal.
Some key elements being implemented focus on data collection via interviews and questionnaires with patients to receive feedback on current health care services and the impact they’ve had on patient needs. This data is then used by case managers and research teams to supervise the day-to-day management of the project. Facilitating co-ordination, remediation of any potential problems, and monitoring progress against the intended schedule.
It is too early to grasp the long-term effects of the project but so far, we have heard reports that the teams ‘on the ground’ such as clinical staff and case managers are engaged and interested in improving the quality of patients’ lives within communities that need it the most.
“…it is imperative to continue developing a health and social services system in which primary care ensures access to and continuity of services for the most vulnerable people in times of crisis…” – An excerpt from an essay co-written by Dr. Catherine Hudon