Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec

Abstract

Background In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models’ similarities and differences. Methods We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS’s components included in the initially designed program, Mitchell and Lewis (2003)’s logic model framework, and Chaudoir and colleagues (2013)’s framework on contextual factors’ influence on an innovation’s implementation. Results Findings show the APSS-CRDS program’s regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists’ availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors’ influence, like ministerial and medical associations’ involvement, collaborations, the context’s implementation readiness, physician practice characteristics, and the program’s adaptability. Interpretation Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

Perceptions on barriers, facilitators, and recommendations related to mental health service delivery during the COVID-19 pandemic in Quebec, Canada: a qualitative descriptive study

“…For purposeful sampling, we recruited participants through internet searches and through our networks in the study regions. These networks stem from our research team, as well as from a previous project on the functioning and use of the CRDS for all 26 specialties [ 18 ]. For snowball sampling, JS asked participants identified through purposeful sampling if they knew of any key informants potentially interested in the research.…”

“…Specifically, FPs could fill out and submit requests for patient referrals to psychiatrists using a standardized form with predefined levels of prioritization according to the listed reasons for consultation. This form would then be submitted to the centralized referral system, where specialists including psychiatrists were assigned [ 18 ]. The GASMA is a referral mechanism used by FPs and other healthcare professionals, who judge that patients might require community or primary mental health care, or psychiatric services (offered by psychiatrists).…”

“…Non-physician perspectives like those of staff working at mental health referral mechanisms in primary care settings are important to better understand mental health service delivery in the pandemic, as they have also been less studied in this context [5,6]. In Quebec, two mental health referrals mechanisms are available and used by FPs: i) single regional access points (Centres de répartition des demandes de services (CRDS)) for processing requests to specialized health services for a first time consultation with specialists, including specialized psychiatry since 2019 [16][17][18]; ii) Guichets d'accès en santé mentale adulte (GASMA), implemented since 2008 and widely used local mental health service access points for patient mental health evaluation and referral to appropriate local mental health services (psychosocial and/or psychiatric) according to evaluated needs [10,[19][20][21]. The CRDS was implemented as part of a program to improve access to specialized health services, including access to psychiatrists.…”

Toward Iran's health system regionalization: a qualitative approach.

“…They believed that regionalization, more than a process of organizing the health actions and services of the territory, aiming at ensuring the integrity of care, is a political construction that must favour the dialogue among local actors and policymakers to recognize and face the speci c territories' health needs. It comprises structural factors that shape the socio-political context (23). The Macro level of system regionalization is crucial to organizing an integrated health system that is achieved by transparent, accountable governance linked to the territory, focused on sustainable development, and obtained by spatial development strategies (1,24,25).…”