Vulnerable Patients in Primary Care: Nurse Case Management and Self-management Support (V1SAGES)

• Improvement in personal self-efficacy [ Time Frame: 2 weeks and 6 months ] [ Designated as safety issue: No ]
  The patient capacity to self-management mesured by the Self-Efficacy for Managing Chronic Disease instrument.
  
  
• Improvement in self-management practice [ Time Frame: 2 weeks and 6 months ] [ Designated as safety issue: No ]
  The patient capacity to manage their condition and their physical and psychological reaction measured by a subscale of the Health Education Impact Questionnaire (HEIQ).
  
  
• Improvement in health behaviours [ Time Frame: 2 weeks and 6 months ] [ Designated as safety issue: No ]
  Fruit and vegetable consumption, smoking status, alcohol consumption, healthy weight and physical activity.
  
  
• Improvement in patient activation [ Time Frame: 2 weeks and 6 months ] [ Designated as safety issue: No ]
  Patient knowledge, skills and self-confidence in self-management measured by the Patient Activation instrument.
  
  
• Decreasing psychological distress [ Time Frame: 2 weeks and 6 months ] [ Designated as safety issue: No ]
  Measured by the Psychological Distress instrument.
  
  

• Improvement in empowerment. [ Time Frame: 6 months ] [ Designated as safety issue: No ]
  Health education impact measured by the Health Education Impact Questionnaire (HEIQ).
  
  
• Improvement in quality of life [ Time Frame: 6 months ] [ Designated as safety issue: No ]
  Measured by the SF-12.
  
  
• Decreasing use of health services [ Time Frame: 6 months ] [ Designated as safety issue: No ]
  Measured by hospitalizations, emergency room visits and CSSS services use(e.g., psychosocial services or specialized services related to the specific chronic disease.
  
  

• Socio-economic status [ Time Frame: 2 weeks before the intervention ] [ Designated as safety issue: No ]
  
• Social isolation status [ Time Frame: 2 weeks before the intervention ] [ Designated as safety issue: No ]
  Measured by a subscale of the Nottingham Health Profile.
  
  
• Health literacy status [ Time Frame: 2 weeks before the intervention ] [ Designated as safety issue: No ]
  The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions measured by the Newest Vital Sign.
  
  
• Mental health status [ Time Frame: 2 weeks before the intervention ] [ Designated as safety issue: No ]
  Measured by the Hospital Anxiety and Depression Scale.
  
  

Chronic diseases represent a major health burden worldwide. Some people with chronic diseases require a higher level of care due to personal characteristics that increase their vulnerability. For these patients, nurse effective case management in primary care are associated with positive outcomes. Moreover, self-management programs, such as the Standford program developed by the School of Medicine at the University of Standford in California (USA), are also recognized for their benefits on patients with chronic diseases.

The aim of our project is to implement, within four (4) FMGs of the region of Saguenay-Lac-Saint-Jean , a practical intervention involving case management by a nurse to promote interdisciplinary person-centered monitoring and self-management support for highly vulnerable individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory diseases, musculoskeletal diseases and/or chronic pain).

The objectives of our study : 1) To analyze the implementation of the intervention in the participating FMGs in order to determine how the various contexts have influenced the implementation and the observed effects; 2) To evaluate the proximal and intermediate effects of the intervention on patients; 3) To conduct an economic analysis of the effectiveness and cost-benefit of the intervention.

The analysis of the implementation will be conducted using realistic evaluation approaches and participatory practice within four categories of key players (FMG stakeholders, FMG/health center managers, patients and their families, health center partners or communities). The data will be obtained through individual or group interviews, literature reviews and documentation from the intervention undertaken. The evaluation of the effects in patients will be based on a pragmatic randomized experimental design before and after (six months) with delayed intervention in the control group. Economic analysis will include a cost-effectiveness analysis and a cost-benefit analysis.