Submitted by Daniele Santos (danielesantos.htl@gmail.com) on 2017-02-21T20:29:41Z No. of bitstreams: 1 Gus Davidson.pdf: 970488 bytes, checksum: 476e7012037f6f72d871810a4fdaf8f5 (MD5) / Approved for entry into archive by Janete de Oliveira Feitosa (janete.feitosa@fgv.br) on 2017-02-23T16:38:01Z (GMT) No. of bitstreams: 1 Gus Davidson.pdf: 970488 bytes, checksum: 476e7012037f6f72d871810a4fdaf8f5 (MD5) / Made available in DSpace on 2017-02-24T12:39:36Z (GMT). No. of bitstreams: 1 Gus Davidson.pdf: 970488 bytes, checksum: 476e7012037f6f72d871810a4fdaf8f5 (MD5) Previous issue date: 2016-11-10 / Health care is a rapidly evolving industry with new technologies constantly entering the marketplace. Supply for quality care has to continuously catch up to demand. The United States’ primary care system is at a crossroads, as patients rightly demand the best in health care costs, access, and quality. How will the industry continue to deliver high quality of care with our nation’s increasing demands? What technologies can be best utilized when caring for our aging population? This thesis is built around key sections that address our country’s impending physician shortage and how our health care system can combat growing demand with better processes and technologies. First, this thesis will examine physician shortages in America and what opportunities are available to address the problem. Existing health care research has found that advanced practice providers improve the costs, access, and quality of care as a solution to the impending shortage. This review will also assess the effectiveness of advanced care providers and health systems using telehealth, and how technology can alleviate the primary care physician shortage. An analysis was also conducted to document the United States’ current ratio of physician to patients in each state, which shows that adding advanced primary care providers and telehealth services can narrow the gap between supply and demand in most states. Second, this thesis will analyze the impact of telehealth in the U.S. health care system. A literature review of telehealth’s definition and history will give a foundation of how the technology has already changed how Americans access care, especially in rural areas. This thesis is proposing that advance practice providers can deliver primary care services using telehealth. Through the review of studies and literature, in addition to interviews with industry experts, it is suggested that there is a lack of concrete evidence with which to fully assess the economic impact of telehealth. Two of the most common economic evaluation methods are cost-utility analysis (CUA) and cost-effectiveness analysis (CEA). The main x objective of CUA, which is used especially in health technology assessment, is to estimate the ratio between the cost of a health-related intervention and the benefit it produces in terms of the number of years lived in full health by the users. In health technology assessments, the benefits are usually expressed in quality adjusted life years.1

Purpose: The purpose of this project is to increase the number of open patient appointments by implementing a validated process in which stabilized behavioral health patients are repatriated to primary care. Currently, there is an increased demand for behavioral health services and decreased supply of behavioral health clinicians at the Nashville Veterans Affairs Medical Center (VAMC). Aims: This project aims to teach behavioral health providers how to identify appropriate patients and complete successful discharges while helping primary care providers integrate the repatriation process into their workflow. Without the proposed intervention, veterans initiating behavioral health services in the catchment area will continue to experience delays. Methods: The Knowledge to Action Framework is being used to adapt the process to the local context. All behavioral health and primary care clinicians at the Nashville VAMC are included in project knowledge dissemination. Data is collected by tracking the behavioral health discharge note within the site. The number of discharge notes per month will be analyzed by comparing the number of discharge notes from previous years to those after project implementation. Results: Results are ongoing, however preliminary results from January and February of 2022 look promising with a total of 35 discharge notes, compared to the six discharge notes from the same months in 2019, 11 in 2020, and 15 in 2021. Conclusion: Preliminary results are encouraging, as the number of successful discharges has significantly increased. This allows for more veterans with mental health needs to be served at the Nashville VAMC.

A atenção primária é recomendada como um princípio organizador para os sistemas de saúde, preconizando, dentre outros aspectos, a acessibilidade, a utilização e longitudinalidade nos serviços de atenção primária, que este trabalho buscou conhecer no município de Uberaba. Para tanto, foram avaliadas: a acessibilidade dos serviços de atenção primária; a utilização do serviço de referência de atenção primária pela população adstrita; a capacidade de a população adstrita identificar qual é o serviço de referência de atenção primária da área onde mora; a opinião do usuário sobre a capacidade dos profissionais de saúde em identificar a população adstrita à área de atuação de seu serviço de saúde; a percepção do usuário sobre a existência de laços interpessoais (vínculo) entre os usuários dos serviços de saúde e os profissionais da equipe. Propôs-se a avaliar, ainda, se a estratégia adotada para o processo assistencial nos serviços de atenção primária estudados, influenciou na acessibilidade, utilização e longitudinalidade da atenção ofertada. Este é um estudo do tipo quantitativo, descritivo e transversal realizado por meio da aplicação de um questionário em domicílios selecionados aleatoriamente no Distrito Sanitário II (DSII), no município de Uberaba, MG. Foram realizadas 795 entrevistas nos domicílios selecionados por amostragem sistemática, no período de setembro de 2005 a março de 2006. Na amostra estudada, 74% dos entrevistados sabiam identificar a localização da unidade de saúde do seu bairro. A análise dos dados mostrou que, na percepção de 96% das pessoas entrevistadas, não existiam barreiras importantes que prejudicassem a acessibilidade quanto ao aspecto geográfico. Entretanto, foram identificados valores muito aquém daqueles considerados adequados, na literatura consultada, na investigação do tempo de espera para obtenção tanto de atendimento na recepção dos serviços, quanto de procedimentos clínicos ou de prevenção/promoção da saúde. Os achados deste estudo sugeriram, ainda, que a forma de organização do trabalho e o horário de funcionamento das unidades de atenção primária à saúde foram obstáculos organizacionais que dificultaram o acesso das pessoas aos serviços oferecidos. Cerca de 69,3% dos entrevistados referiram utilizar a sua unidade básica de saúde de referência, para obtenção de algum tipo de atendimento, havendo variação nesse percentual dependendo do tipo de procedimento investigado. Os resultados desta pesquisa sinalizam para uma baixa vinculação entre usuários e profissionais dos serviços estudados, apontando, ainda, para uma incipiente utilização da unidade de referência como fonte regular de atenção ao longo do tempo. Para avaliação comparada entre as diferentes áreas de abrangência do DSII e as distintas formas de assistência foram atribuídos pontos para os percentuais alcançados em cada característica investigada. A análise dos dados sugeriu que a organização do serviço por meio da estratégia de saúde da família melhorou a capacidade de identificação da unidade de referência, sem, entretanto, repercutir na utilização da mesma. Apesar dos baixos escores alcançados em todas as áreas de abrangência, para a acessibilidade organizacional, as áreas organizadas com equipes de saúde da família apresentaram escores discretamente mais elevados, sugerindo que esta forma de organização dos serviços de saúde favoreça os aspectos organizacionais investigados. Quanto à utilização dos serviços, identificou-se pequeno impacto da estratégia adotada para organização do processo assistencial, nos serviços de atenção primária das áreas de abrangência estudadas, sobre a utilização dos mesmos pela população adstrita. A avaliação dos aspectos ligados à relação entre usuários e profissionais de saúde obteve escores baixos em todas as áreas de abrangência estudadas. A capacidade de usuários e profissionais de saúde se identificarem pelo nome obteve escores discretamente mais elevados nas áreas que têm seus serviços organizados com equipes de saúde da família. Assim, parece adequado supor que a estratégia da saúde da família favorece que usuários e profissionais se identifiquem pelo nome, principalmente os usuários em relação aos profissionais da equipe. Essa observação é válida também para a análise da percepção dos usuários sobre a capacidade da equipe conhecer bem a eles e seus familiares. Os achados não permitiram relacionar a capacidade das equipes das unidades responderem às necessidades dos usuários, com a estratégia de organização dos serviços de saúde na área estudada. O componente da longitudinalidade, investigado pela percepção do usuário sobre a atenção prestada com foco na pessoa, foi o aspecto que recebeu a menor pontuação. Os achados desta avaliação não apontaram para impacto da estratégia de organização dos serviços de saúde na formação de vínculo entre usuários e profissionais dos serviços estudados. / Primary care is recommended as an organizing principle for health systems. The objective of the present investigation was to obtain in-depth knowledge about the accessibility, utilization and longitudinality of primary care services in the municipality of Uberaba. To this end, the authors evaluated the accessibility, the utilization of the reference service by the population served and the ability of these persons to identify the primary care reference service in the area where they live; the opinion of users about the ability of the health professionals to identify the population served by the area of action of its health service; the perception of users regarding the existence of interpersonal bonding between the users of the health services and the professionals of the health team. An additional objective was to evaluate whether the strategy adopted for the assistance process at the primary care services studied influenced the accessibility, utilization and longitudinality of the care offered. This was a quantitative, descriptive and transverse study conducted by applying a questionnaire to randomly selected households in the Sanitary District II (SDII) of the municipality of Uberaba, MG. A total of 795 interviews were held in the households selected by systematic sampling during the period from September 2005 to March 2006. Results and discussion: 74% of the interviewees were able to identify the location of the health unit in their neighborhood. Data analysis showed that 96% of the persons interviewed did not perceive the existence of important barriers that would impair accessibility in geographical terms. However, values much lower than those considered to be adequate in the literature consulted were identified regarding waiting time before being attended at the reception of the service unit and before receiving clinical procedures or procedures of health prevention/promotion. The present findings also suggest that the type of work organization and the hours of functioning of the primary health care units were organizational obstacles that impaired the access of the persons to the services offered. Only 69.3% of the interviewees stated that they utilized the reference primary care health unit in the area where they reside in order to obtain some type of care, a percentage that varied widely according to the type of procedure investigated. The results of the present investigation indicate low bonding between the users and professionals of the services studied, as well as an only incipient utilization of the reference unit as a regular source of care along time. In the comparative evaluation between the different areas of coverage of the SDII and the different forms of care, scores were attributed regarding the percentages reached in each characteristic investigated. Data analysis suggested that the organization of the service based on a strategy of family health improved the ability to identify the reference unit, but with no effect of its utilization. Despite the low scores reached in all areas of coverage for organizational accessibility, the areas organized with family health teams presented slightly higher scores, suggesting that this form of organization of health services favors the organizational aspects investigated. Analysis of the data regarding the utilization of the services also indicated a low impact of the strategy adopted for the organization of the assistance process in the primary care services of the areas studied on the utilization of these services by the population served. The evaluation of aspects involving the relationship between users and health professionals yielded low scores in all areas studied. The ability of users and health professionals to identify each other by name obtained slightly higher scores in the areas where the services are organized with family health teams. Thus, it seems appropriate to assume that the family health strategy favors the identification of users and professionals by name, especially for the users in relation to the professionals. This observation is also valid for the analysis of user perception of the ability of the team to become well acquainted with both users and their families. The data did not permit us to relate the ability of the unit teams to respond to the necessities of the users to the organization strategy of the health services in the study area. The longitudinality component, investigated on the basis of the perception of the user regarding the care provided with emphasis on the person, was the aspect that received the lowest score. The findings of this evaluation did not indicate an impact of the strategy of organization of health services regarding the formation of bonding between users and health professionals.

A atenção primária é recomendada como um princípio organizador para os sistemas de saúde, preconizando, dentre outros aspectos, a acessibilidade, a utilização e longitudinalidade nos serviços de atenção primária, que este trabalho buscou conhecer no município de Uberaba. Para tanto, foram avaliadas: a acessibilidade dos serviços de atenção primária; a utilização do serviço de referência de atenção primária pela população adstrita; a capacidade de a população adstrita identificar qual é o serviço de referência de atenção primária da área onde mora; a opinião do usuário sobre a capacidade dos profissionais de saúde em identificar a população adstrita à área de atuação de seu serviço de saúde; a percepção do usuário sobre a existência de laços interpessoais (vínculo) entre os usuários dos serviços de saúde e os profissionais da equipe. Propôs-se a avaliar, ainda, se a estratégia adotada para o processo assistencial nos serviços de atenção primária estudados, influenciou na acessibilidade, utilização e longitudinalidade da atenção ofertada. Este é um estudo do tipo quantitativo, descritivo e transversal realizado por meio da aplicação de um questionário em domicílios selecionados aleatoriamente no Distrito Sanitário II (DSII), no município de Uberaba, MG. Foram realizadas 795 entrevistas nos domicílios selecionados por amostragem sistemática, no período de setembro de 2005 a março de 2006. Na amostra estudada, 74% dos entrevistados sabiam identificar a localização da unidade de saúde do seu bairro. A análise dos dados mostrou que, na percepção de 96% das pessoas entrevistadas, não existiam barreiras importantes que prejudicassem a acessibilidade quanto ao aspecto geográfico. Entretanto, foram identificados valores muito aquém daqueles considerados adequados, na literatura consultada, na investigação do tempo de espera para obtenção tanto de atendimento na recepção dos serviços, quanto de procedimentos clínicos ou de prevenção/promoção da saúde. Os achados deste estudo sugeriram, ainda, que a forma de organização do trabalho e o horário de funcionamento das unidades de atenção primária à saúde foram obstáculos organizacionais que dificultaram o acesso das pessoas aos serviços oferecidos. Cerca de 69,3% dos entrevistados referiram utilizar a sua unidade básica de saúde de referência, para obtenção de algum tipo de atendimento, havendo variação nesse percentual dependendo do tipo de procedimento investigado. Os resultados desta pesquisa sinalizam para uma baixa vinculação entre usuários e profissionais dos serviços estudados, apontando, ainda, para uma incipiente utilização da unidade de referência como fonte regular de atenção ao longo do tempo. Para avaliação comparada entre as diferentes áreas de abrangência do DSII e as distintas formas de assistência foram atribuídos pontos para os percentuais alcançados em cada característica investigada. A análise dos dados sugeriu que a organização do serviço por meio da estratégia de saúde da família melhorou a capacidade de identificação da unidade de referência, sem, entretanto, repercutir na utilização da mesma. Apesar dos baixos escores alcançados em todas as áreas de abrangência, para a acessibilidade organizacional, as áreas organizadas com equipes de saúde da família apresentaram escores discretamente mais elevados, sugerindo que esta forma de organização dos serviços de saúde favoreça os aspectos organizacionais investigados. Quanto à utilização dos serviços, identificou-se pequeno impacto da estratégia adotada para organização do processo assistencial, nos serviços de atenção primária das áreas de abrangência estudadas, sobre a utilização dos mesmos pela população adstrita. A avaliação dos aspectos ligados à relação entre usuários e profissionais de saúde obteve escores baixos em todas as áreas de abrangência estudadas. A capacidade de usuários e profissionais de saúde se identificarem pelo nome obteve escores discretamente mais elevados nas áreas que têm seus serviços organizados com equipes de saúde da família. Assim, parece adequado supor que a estratégia da saúde da família favorece que usuários e profissionais se identifiquem pelo nome, principalmente os usuários em relação aos profissionais da equipe. Essa observação é válida também para a análise da percepção dos usuários sobre a capacidade da equipe conhecer bem a eles e seus familiares. Os achados não permitiram relacionar a capacidade das equipes das unidades responderem às necessidades dos usuários, com a estratégia de organização dos serviços de saúde na área estudada. O componente da longitudinalidade, investigado pela percepção do usuário sobre a atenção prestada com foco na pessoa, foi o aspecto que recebeu a menor pontuação. Os achados desta avaliação não apontaram para impacto da estratégia de organização dos serviços de saúde na formação de vínculo entre usuários e profissionais dos serviços estudados. / Primary care is recommended as an organizing principle for health systems. The objective of the present investigation was to obtain in-depth knowledge about the accessibility, utilization and longitudinality of primary care services in the municipality of Uberaba. To this end, the authors evaluated the accessibility, the utilization of the reference service by the population served and the ability of these persons to identify the primary care reference service in the area where they live; the opinion of users about the ability of the health professionals to identify the population served by the area of action of its health service; the perception of users regarding the existence of interpersonal bonding between the users of the health services and the professionals of the health team. An additional objective was to evaluate whether the strategy adopted for the assistance process at the primary care services studied influenced the accessibility, utilization and longitudinality of the care offered. This was a quantitative, descriptive and transverse study conducted by applying a questionnaire to randomly selected households in the Sanitary District II (SDII) of the municipality of Uberaba, MG. A total of 795 interviews were held in the households selected by systematic sampling during the period from September 2005 to March 2006. Results and discussion: 74% of the interviewees were able to identify the location of the health unit in their neighborhood. Data analysis showed that 96% of the persons interviewed did not perceive the existence of important barriers that would impair accessibility in geographical terms. However, values much lower than those considered to be adequate in the literature consulted were identified regarding waiting time before being attended at the reception of the service unit and before receiving clinical procedures or procedures of health prevention/promotion. The present findings also suggest that the type of work organization and the hours of functioning of the primary health care units were organizational obstacles that impaired the access of the persons to the services offered. Only 69.3% of the interviewees stated that they utilized the reference primary care health unit in the area where they reside in order to obtain some type of care, a percentage that varied widely according to the type of procedure investigated. The results of the present investigation indicate low bonding between the users and professionals of the services studied, as well as an only incipient utilization of the reference unit as a regular source of care along time. In the comparative evaluation between the different areas of coverage of the SDII and the different forms of care, scores were attributed regarding the percentages reached in each characteristic investigated. Data analysis suggested that the organization of the service based on a strategy of family health improved the ability to identify the reference unit, but with no effect of its utilization. Despite the low scores reached in all areas of coverage for organizational accessibility, the areas organized with family health teams presented slightly higher scores, suggesting that this form of organization of health services favors the organizational aspects investigated. Analysis of the data regarding the utilization of the services also indicated a low impact of the strategy adopted for the organization of the assistance process in the primary care services of the areas studied on the utilization of these services by the population served. The evaluation of aspects involving the relationship between users and health professionals yielded low scores in all areas studied. The ability of users and health professionals to identify each other by name obtained slightly higher scores in the areas where the services are organized with family health teams. Thus, it seems appropriate to assume that the family health strategy favors the identification of users and professionals by name, especially for the users in relation to the professionals. This observation is also valid for the analysis of user perception of the ability of the team to become well acquainted with both users and their families. The data did not permit us to relate the ability of the unit teams to respond to the necessities of the users to the organization strategy of the health services in the study area. The longitudinality component, investigated on the basis of the perception of the user regarding the care provided with emphasis on the person, was the aspect that received the lowest score. The findings of this evaluation did not indicate an impact of the strategy of organization of health services regarding the formation of bonding between users and health professionals.

Problématique : L’accessibilité à des soins de santé de qualité se trouve au cœur des objectifs gouvernementaux en matière de santé. Elle demeure toutefois, et ce depuis de nombreuses années, un point faible de notre réseau bien qu’au cours des cinquante dernières années, de nombreuses recommandations aient été faites afin d’améliorer notre système de santé. Les commissions Castonguay-Nepveu (1967), Rochon (1988) et Clair (2000) ont notamment mis de l’avant l’importance d’améliorer l’accessibilité aux soins de première ligne afin d’offrir de meilleurs soins à l’ensemble de la population. Le problème persiste néanmoins depuis tout ce temps et contribue à l’engorgement des urgences, où plus de 60% des visites sont effectuées par des patients ayant des problématiques de santé considérées comme moins urgentes et non urgentes (Commissaire à la santé et au bien-être, 2016). Parmi les différentes solutions possibles avancées pour désengorger les urgences, la réorientation d’une portion de cette clientèle vers les ressources de première ligne est une des solutions déjà implantées dans plus de la moitié des urgences du Québec (Commissaire à la santé et au bien-être, 2016). Aucune étude, jusqu’à présent, n’a documenté les différents mécanismes de réorientation présents au Québec ni analysé leur fonctionnement. But : Ce mémoire vise donc à documenter et analyser le processus par lequel les patients présentant des problématiques de santé moins urgentes ou non urgentes sont redirigés vers des ressources de soins primaires dans un département d’urgence de la région métropolitaine. Méthodologie : Le devis retenu pour cette étude est un devis qualitatif par étude de cas avec un échantillonnage par choix raisonné composé de cinq personnes provenant d’un département d’urgence (trois infirmières, un gestionnaire infirmier et un médecin). Les résultats ont, par la suite, été analysés en fonction du Patient Care Delivery Model (O’Brien-Pallas, Meyer, Hayes & Wang, 2011) et d’une analyse logique du mécanisme de réorientation étudié. Résultats et discussion : Bien qu’il ait certaines limites évidentes, ce mécanisme de réorientation est apprécié par l’équipe de l’urgence de ce centre où de nombreux effets positifs ont été perçus notamment une diminution du nombre de patients dans la salle d’attente, une diminution du temps d’attente et une diminution perçue de la charge de travail du côté des infirmières du triage. Les différents membres de l’équipe s’entendent pour dire qu’il est sécuritaire et qu’il a permis d’atteindre les objectifs fixés par l’administration. Ce mécanisme pourrait être amélioré, adapté et transféré à d’autres ressources de santé afin d’améliorer la qualité des soins à la population. D’autres études seront cependant nécessaires pour comparer celui-ci à d’autres présents dans la province, mesurer leurs effets et pour ajouter les perceptions des acteurs de soins primaires et la perspective du patient.. Conclusion : Ce mécanisme représente un changement de mentalité au sein des départements d’urgence, passant d’une prise en charge complète des patients se présentant à l’urgence par les médecins d’urgence à une collaboration interprofessionnelle permettant de répartir la prise en charge sur davantage d’acteurs du réseau afin d’améliorer les soins à la population. / Problematic : Access to quality health care services is at the heart of government’s health objectives. For many years, it has remained a weak link in the services offered to the population even though, over the past fifty years, several recommendations have been made in an attempt to improve our health care system. The Castonguay-Neveu commission (1967), the Rochon commission (1988) and the Clair commission (2000) have all put forward the importance of improving access to primary care in order to dispense better care to the entire population. However, the problem remains and contributes to emergency department crowding as over 60% of all visits are made by patients whose health problems can be considered less urgent or non-urgent (Commissaire à la santé et au bien-être, 2016). Amongst the different possible solutions to alleviate emergency department crowding, reorienting a portion of those patients towards a primary care setting is one that has already been implemented in over half of Quebec’s emergency departments (Commissaire à la santé et au bien-être, 2016). So far, no study has documented the different reorientation mechanisms that are present in Quebec, nor have they analysed their functioning. Purpose : This study aims at documenting and analysing the process by which patients coming in the emergency department of the Montreal area with a health problem deemed less urgent or non urgent can be diverted to a primary care setting. Methods: This qualitative study is a case study with a purposive sampling constituted of five participants from an emergency department (three nurses, one head nurse and one emergency physician). Results have then been analysed based on the Patient Care Delivery Model (O’Brien-Pallas et al., 2011) and by logical analysis of this reorientation mechanism. Results and discussion: Even though there are some obvious limits to this study, the reorientation mechanism is appreciated by the emergency department’s staff and several positive effects have been noted such as having fewer patients in the waiting room, lower waiting times for the patients remaining in the waiting room and a perceived reduced workload for the triage nurses. The different team members agree that it is safe and has allowed to achieve the objectives set by the hospital’s administration. This mechanism could be improved, adapted and transferred to other health resources in order to improve the quality of care to the population. Further studies will be needed in order to compare this mechanism with others that are present in the province, to add the perceptions of the primacy care workers and the patient’. It would also be interesting to consider a quantitative approach to measure the outcomes described here. Conclusion: This mechanism represents a mentality shift amongst emergency departments, going from emergency physicians completely taking charge of all patients coming to the emergency department to an interprofessional collaboration that divides the workload on more health care works in the system in order to improve care to the population.

Problématique : Au Québec, les troubles anxieux et dépressifs touchent près d’une personne sur cinq au cours de leur vie. Elles consultent majoritairement dans les services de première ligne (SPL) qui sont souvent dispensés en collaboration interprofessionnelle, mais qui ne semblent pas répondre efficacement à leurs besoins. Le rôle optimal (RO) infirmier permet d’intervenir lors du continuum de services. Un écart entre les rôles réels (RR) et le RO des infirmières semble s’observer dans les SPL. But : Décrire et analyser le RR de l’infirmière lors de la prestation des soins aux personnes atteintes de troubles dépressifs et anxieux dans les équipes multiprofessionnelles de première ligne. Méthodologie : 15 professionnels de la santé (infirmières [n=9], autres [n=6]) dans deux milieux de SPL ont participé à cette étude de cas multiples qualitative. Résultats : Trois catégories de facteurs influencent l’écart entre les RR et le RO des infirmières, soit les facteurs liés : 1) à l’équipe, 2) à la clientèle et 3) aux infirmières. La formation du RO des infirmières influence également l’écart. L’approche typiquement holistique et non stigmatisante des infirmières ainsi que la réduction de l’écart entre les RR et le RO semblent optimiser la prise en charge des TMC dans les SPL. Conclusion : Cette recherche met en lumière les facteurs pour réduire l’écart entre les RR et le RO. La formation des professionnels et l’organisation du travail dans le milieu clinique devrait mettre l’accent sur la collaboration interprofessionnelle, maximisant ainsi la pratique des professionnels selon leurs RO. / Problematic: In Québec, anxiety and depressive disorders affect nearly one in five people in their lives. They mainly consult in primary care services which are often provided in interprofessional collaboration but does not seem to succeed to effectively meet their needs. The optimal role allows nurses to intervene throughout the care plan. A difference between the nurse’s actual and optimal roles seems to be observed in the primary care services. Purpose: To describe and analyze the nurse’s actual roles in primary care multiprofessional teams during the delivery of care to people with depressive and anxiety disorders. Methods: 15 healthcare professionals (nurses [n=9], others [n=6]) in two primary care service environments participated in this qualitative multiple case study. Results: Three categories of factors influence the difference between the nurses’ actual and optimal roles: 1) the team, 2) the customer and 3) the nurses. Nurse’s training on the optimal role also influences the gap. The typical nurse’s holistic approach and the nurse’s actual role approaching the optimal role seem to contribute to primary care services in mental health. Conclusion: University training for health professionals and the organization of work in the clinical setting should focus on interprofessional collaboration, maximizing the contribution of optimal role. This research highlights the factors to reduce the gap between the nurse’s actual and optimal roles.

Between 2013 and 2016, 8.1% of U.S. adults 20 years and older suffered from depression, but only 29% of them sought help. This project addressed the low depression screening rate in a Federally Qualified Health Center (FQHC) that supported integrated care. The purpose of the project was to evaluate the integration of behavioral health into primary care in an FQHC through the rate of depression screenings. Two theoretical frameworks, the find-organize-clarify-understand-select/plan-do-study-act model and the Centers for Disease Control and Prevention's framework for program evaluation in public health were combined into a list of questions and data validity tests that were used to conduct the evaluation. This quality improvement (QI) project evaluated an existing QI initiative. Findings revealed that 75% of the patients seen, and not the initially reported 53%, received depression screenings, which indicated an improved outcome. Other findings were inadequate use of theoretical frameworks, poor data quality, and suboptimal effectiveness of QI team processes. The strategies and tools recommended in this project could be used by organizational leaders and QI teams to evaluate and improve QI initiatives. The project's contribution to awareness about depression through integrated care could increase patients' access to care, quality of life, and life expectancy, and positively impact social change.