Leading change in the large-scale implementation of a service integration model in Québec

Abstract

Introduction: Conceptual models and empirical evidence of efficiency are accumulating about service integration. However, the effects demonstrated during pilot projects are not always translated to effective practices during the scale up of integrated services at the national level. We hypothesize that a defect in the conduct of change may explain this knowledge-practice gap. Description of policy context and objective: After 10 years of research and promising experimental projects, Québec has made service integration one of the pillars of two major reforms (2004 and 2015) of its health and social services system. These reforms constituted continuums of care under the responsibility of a single organization responsible for the needs of the population of its territory. Specifically, these organisations were given all the necessary managerial means to integrated management of the health and social services system. While both reforms have had a profound impact on the six dimensions of the Rainbow Model of Integrated Care (Valentijn et al., 2015), public action has been deployed at variable intensities for each of them. Targeted population: The entire Québec population receiving health and social services. Highlights: We conducted 13 in-depth semi-structured interviews with very senior managers (former ministers, CEOs, senior officials). These interviews focused on understanding issues driving the change of the two reforms aimed at integrating services. The variation observed in the intensity of the change according to the components of the Rainbow model reveals a public action of the "make-it-happen" type on some components the State prioritised (e.g. merging organizations, clinical evaluation tools), and "help-it-happen" (e.g. case management) or "let-ithappen" for others (e.g. individualized service plan), deemed of secondary importance. This shift in change management strategies has had the effect of disrupting an integrated service integration model which was conceptually integrated. Comments on transferability: This analysis makes it possible to think about the necessary balance between change management strategies types such as make it, help it and let it happen. At the end of this work, we believe that it is less a question of choosing one of these three strategies, nor of choosing between a top-down approach, imposing a single model, or bottom-up, asking local actors to adapt a general model to their particular context. The study shows the need to develop an integrated vision of change management, sensitive to the potential effects of a too variable intensity of a differentiated strategy according to the dimensions of the integration of the services considered.