Fall 2023 Guest Lecture 222 Miller myCourses PDF

Health Care Organization, Public Health, Health Equity, SDoH & Leadership NUR1 222 November 2 2023 Copyrighted ISoN @Catherine-Anne Miller Photos @ CC, Miller, and Unsplash Content – do not reproduce Images cited or @ Creative Commons @ Unsplash https://www.sacisc.gc.ca/eng/1634312499368/163431...

Health Care Organization, Public Health, Health Equity, SDoH & Leadership NUR1 222 November 2 2023 Copyrighted ISoN @Catherine-Anne Miller Photos @ CC, Miller, and Unsplash Content – do not reproduce Images cited or @ Creative Commons @ Unsplash https://www.sacisc.gc.ca/eng/1634312499368/1634312554965 Treaty 1: Gaawijijigemangit Agreement signature - NaawiOodena Class Objectives : The Student will be able to… § Describe the roles of the federal and provincial & territorial governments in health § Summarize and define key components of the Canada Health Act (CHA) § Name, recognize and describe structures in the Quebec healthcare system § Recognize level of care delivery with examples § Describe/define the key functions of public health § Provide examples of each function as related to nursing practice § Define and describe levels of prevention & link to practice PART 1 PART 2 § Describe how social justice is embedded in nursing practice § Discuss the importance and impact of Structural & Social Determinants of Health § Discuss the concept of health equity § Recognize approaches to target health equity in Canada PART 3 § Name and define leadership competencies as described by CHNC (2015) § Reflect on the importance of leadership in nursing PART 4 7:34 PM During presentation try to reflect on: How does the content being presented inform my nursing practice (me using a SBNH approach)? What areas would I explore with patients/families/communities? Questions I could ask to explore identified areas ? How does understanding the health system shift how you assess and intervene? 7:34 PM PART 1 Canada and Quebec Health Care Organization 7:34 PM Leigh Chapman Chief Nursing Officer You want to know more! https://www.cna-aiic.ca/en/blogs/cncontent/2022/08/23/leigh-chapman-new-chiefnursing-officer https://www.canada.ca/en/healthcanada/news/2022/08/backgrounder-chief-nursingofficer-biography.html Citation: https://www.canadian-nurse.com/blogs/cncontent/2022/08/24/leigh-chapman-chief-nursing-officer PART 1 History of Healthcare in Canada 7:34 PM “Health care in Canada is complex, diffuse and decentralized arrangement of actors and services. Although we sometimes speak of the Canadian Healthcare system, there is no single, national health system. Rather, there are 14 single-payer, universal, and public systems.” “ CIHI, 2014, Healthcare priorities in Canada: A Backgrounder. P.1 * Medicare 1947: Father of Medicare: Tommy Douglas in Saskatchewan 1966: Lester B. Pearson's government expanded this policy to universal health care with the Medical Care Act: * Canada Health Act ▸1984 ▸Monique Bégin and P-E Trudeau ▸CNA helped amend language as to who are ‘health care professionals’ ▸Federal funding would continue so long as provinces met certain criteria 7:34 PM * Health Canada (2017) http://hc-sc.gc.ca/hcs-sss/medi-assur/cha-lcs/index-eng.php * 5 important criteria: ▸ Public administration ▸ Comprehensive ▸ Universal ▸ Portable ▸ Accessible P-CUPA “ * Hitchcock, JE, Schubert, PE, Thomas, SA, Bartfay, W. J. (2010): Community Health Nursing: Caring in Action (1st Canadian Edition). Nelson Education, Toronto, Ontario (ISBN 13:978-0-17-644103-6 and 10: 0-17-644103-4).p.32 Because protective, preventive, and health promotion services were not required to meet the five criteria of medicare, they were not subject to the conditions of the act. (...) Each province, territory, and region determines what services are covered and to what extend. The result has been varied and fragmented community health services across the country.” “ Tsasis (2009) as referenced in Betker and Bewick (2016) Financing, Policy, and Politics of Healthcare Delivery. P. 19 * Federal Vs. Provinces-Territories Federal Provinces-Territories - Standards and administering these through CHA - Provision of funding - Health Care for specific groups - Other functions- Regulation of products, Tax support for health related, health promotion, prevention and monitoring - All medically necessary services provided by hospitals, physicians. ‘Medically necessary’ is determined by provinces and territories. 7:34 PM * Under Federal Responsibility ▸ First Nations peoples living on reserves ▸ Inuit ▸ serving members of the Canadian Forces ▸ eligible veterans ▸ inmates in federal penitentiaries ▸ some groups of refugee claimants 7:34 PM * Health Canada (2017) Public Health Agency of Canada ▸ Health emergencies ▸ Established PHAC in 2004 – officialised in 2005 ▸ Reports to Parliament through Minister of Health ▸ Mission to ‘promote and protect the health of Canadians’ ▸ Within the mandate of the Health Minister https://www.canada.ca/en/healthcanada/corporate/health-portfolio.html 7:34 PM * 1:03 PM PART 1 Quebec Organization Some stats specific to Quebec ▸Prevalence of chronic diseases is increasing faster in Quebec than elsewhere in Canada. ▸“Multimorbidity: 50% of patients seen in primary care have 5 or + chronic diseases - which increases to 70% for over 65” p.2 ▸Chronic care poses challenges to quality of care ▸Silos between different levels of care delivery Vedel, I. et al. (2011) Ten years of integrated care: backwards and forwards. The care of the province of Quebec, Canada. International Journal of Integrated Care. 11. ISSN 1568-4156. 7:34 PM 1:03 PM What are the Quebec organizational entities you need to know? ▸ RUIS ▸ CIUSSS/CISSS ▸ CLSC ▸ GMF/Clinique Reseau 7:34 PM 1:03 PM RUIS ▸ Réseau Universitaire Intégré de Santé (RUIS) in 2003 ▸ Facilitate specialized care, medical education, and medical research throughout the province’s many regions ▸ Favoring complementarity and integration of care ▸ Mandate to institute a culture of collaboration « Afin de favoriser la concertation, la complémentarité et l'intégration des missions de soins, d'enseignement et de recherche des établissements de santé ayant une désignation universitaire et des universités auxquelles sont affiliés ces établissements pour chaque territoire de desserte que détermine le ministre de concert avec le ministre de l'Enseignement supérieur, de la Recherche, de la Science et de la Technologie, un réseau universitaire intégré de santé. » (Art. 436.1) 7:34 PM 1:03 PM RUIS MCGILL ‘With an area spanning 63 per cent of the territory of the province of Quebec – and which includes 7 different regional authorities, 1 University Hospital Centre, 2 CIUSSS, 3 CISSS and three other health centres – RUIS McGill works to offer better access to health care for a population of 1.8 million.’ www.mcgill.ca/ruis/welcome-ruis-mcgill Tele Health ◉ ‘Telehealth: The delivery of health care, health education, and health information services via remote technologies’ 7:34 PM 811 7:34 PM ◉ ◉ https://www.youtube.com/watch?v=fXIYQMjzJlA https://www.quebec.ca/en/health/finding-a-resource/info-sante-811/ ADVANTAGES OF TELEHEALTH ◉ ◉ ◉ ✔ Provides access to the same quality care and services as those offered during appointments in person ✔ Ensures access to specialized health care or the continuity of services in close proximity ✔ Reduces travel as well as travel-related stress and expenses http://telesantemcgill.ca/tswp/home/ Catalyst, N. E. J. M. (2018). What is telehealth?. NEJM Catalyst, 4(1). 1:03 PM CLSC (Centre local de services communautaires) ▸ ▸ ▸ ▸ 7:34 PM * Attempt at integration at a structural level (1970s) Stems from Clinique communautaire Pointe-St-Charles 147 CLSCs in Quebec Wide range of services (in different settings): ▹ ▹ ▹ ▹ Routine health and social services Preventive or nursing services Rehab/Reintegration Public health activities 1:03 PM Family Medicine Groups (GMF) ▸ Groups of family physicians (6-12) who are responsible of a large group of patients (1000-2200) and work in collaboration with nurses and other professionals. Goals: ▸ Improve access to Family MD and hours available ▸ Improve quality, patient follow-up, and continuity of care ▸ Decrease unnecessary visits to ER 1:03 PM Reform succession – Mergers Gallore ▸2003/05: Various mergers to create 95 CSSS ▸Goal: improve accessibility, continuity, integration, and quality of services. ▸Two principles were foundational: 1- Shift from ‘service-based’ to ‘population-based’ approach 2- Hierarchy of services (1-2-3) Vedel et al. (2011) 7:34 PM * We’ll see more about this later! Recent reforms - Bill 10 - 2015 An act to modify the organization and governance of the health and social services network in particular by abolishing the regional agencies @ Wiki 7:34 PM * Wankah, P., Guillette, M., Dumas, S., Couturier, Y., Gagnon, D., Belzile, L., ... & Breton, M. (2018). Reorganising health and social care in Québec: a journey towards integrating care through mergers. London Journal of Primary Care, 1-6. 7:34 PM 1:03 PM Non Merged: Centre hospitalier universitaire SainteJustine Centre hospitalier de l’Université de Montréal (CHUM) McGill University Health Centre (CUSM) Institut de cardiologie de Montréal Institut Philippe-Pinel de Montréal 7:34 PM www.santemontreal.qc.ca/en/montreals-health-network/montreals-institutions-at-a-glance/ciusss/ 1:03 PM The JGH as an example The JGH is located in the CIUSSS du Centre-Ouest-de-l’Île-de-Montréal (the CIUSSS for Centre-West Montreal). JGH Board of Directors has disappeared - A new body at the JGH is created and serves as providing recommendations to the CIUSSS board - but does not establish policy. The CIUSSS includes ▸ Jewish General Hospital ▸ The Maimonides Geriatric Centre, ▸ Mount Sinai Hospital, ▸ Miriam Home and Services, ▸ the Jewish Eldercare Centre, ▸ the Constance-Lethbridge Rehabilitation Centre, ▸ the Cavendish Health and Social Services Centre, and ▸ the de la Montagne Health and Social Services Centre As Cited from the JGH website 7:34 PM 1:03 PM Challenges of proposed changes ▸Change is hard ▸Loss of management positions, reorganization throughout ▸Standardizing budgets/ centralized decision making ▸Takes 8-10 years to adapt to reform COVID-19 arrived 5 years in… 7:34 PM And now a new reform is coming! ◉ The CREATION OF SANTÉ QUÉBEC 1:03 PM Levels of Care Delivery ▸ ▸ ▸ ▸ Primary Secondary Tertiary Quaternary https://muhc.ca/questions/article/question-sample-4 * 7:34 PM A question for the MUHC https://muhc.ca/questions/article/question-sample-4 MELANOMA Let’s use one pathology as a case study! https://www.youtube.com/watch?v=jd36yB_usmM Dear 16 year-old me 7:34 PM Jeff Beach Volleyball player And really loves a tan Spot on his back His family doctor refers him to a dermatologist for an urgent consultation. Which level of care delivery is this? 7:34 PM Aging Population 7:34 PM Institut de la statistique du Québec (2014). Perspectives démographiques du Québec et des régions, 2011-2061, Québec. p.85 The Commonwealth Fund (2014) Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. Retrieved at http://www.commonwealthf und.org/~/media/files/public ations/fundreport/2014/jun/1755_davis _mirror_mirror_2014.pdf 2021 https://www.commonwealthfund.org/sites/default/files/2021-07/PDF_Schneider_Mirror_Mirror_2021_exhibits.pdf ◉ Canadian Institute for Health Information. Canada continues to lag behind other OECD countries on measures of patient safety. Ottawa, ON: CIHI; 2019. Take home from all these tables Canadian Institute for Health Information. International Comparisons at CIHI, February 2017. Ottawa, ON: CIHI; 2017. Available: https://www.cihi.ca/en/oecd-interactive-toolinternational-comparisons 7:34 PM PART 2 PUBLIC HEALTH 7:34 PM PUBLIC HEALTH ◉The organized efforts of society to keep people healthy and prevent injury, illness and premature death. It is a combination of programs, services and policies that protect and promote the health of all Canadians. 7:34 PM ◉ Last, J. (2001). A Dictionary of epidemiology. 4th Edition. Oxford University Press. As cited in PHAC (2008) ◉ http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2008/fr-rc/cphorsphc-respcacsp05a-eng.php 7:34 PM PUBLIC HEALTH ESSENTIAL FUNCTIONS ◉ ◉ ◉ ◉ ◉ ◉ 7:34 PM Health Protection Health Surveillance Population Health Assessment Disease and injury prevention Health Promotion Emergency preparedness/disaster response https://www.cpha.ca/sites/default/files/asset s/history/cpha100-poster_e.pdf PREVENTION Nurses across roles work towards the prevention of disease and injury 3 levels of prevention: ◉Primary ◉Secondary ◉Tertiary 7:34 PM PART 2 Levels of Prevention 7:34 PM Level of Prevention Description Primordial ‘Initiatives that prevent the conditions that would enable the risk factors for disease from developing’ – Often related to Healthy Public Policy Primary -Risks of illness, disease, and injury are eliminated. -Prevents the occurrence of disease. - ‘interrupt the chain of causality’ Secondary -The disease process is suspended before symptoms occur. Causal factors are not eliminated, but permanent sequelae is prevention through early detection or public health programs to control the disease. -Detect and stop disease development in those at risk Tertiary -The impairment or disability from the disease process is halted - Reduce the negative effects once a disease has established itself Quaternary - Actions to identify individuals and populations at risk of overmedicalization. Sheila Dinotshe Tlou Botswana nurse, specialist in HIV/AIDS and women's health, and a nursing educator. She was Minister of Health from 2004 to 2008 Jeff ◉ Beach Volleyball player ◉ And really loves a tan ◉ Spot on his back 7:34 PM Emergency Preparedness/ Disaster Planning 4 Pillars of Emergency Management ◉ Prevention and Mitigation ◉ Preparedness During a natural or human-made disaster, including a communicable disease outbreak, nurses provide care using appropriate safety ◉ Response precautions in accordance with legislation, regulations and guidelines provided by ◉ Recovery government, regulatory bodies, employers, unions and professional associations. A9 CNA Code of Ethics 7:34 PM http://www. wpro.who.i nt/hrh/docu ments/icn_ framework. pdf p.49 “ 7:34 PM SARS and the resurgence of Public Health in Canada with the Naylor Report 57 The SARS experience and the Naylor report brought about the PHAC, but also developed provincial systems for pandemic preparedness 58 STRUCTURAL https://www.canada.ca/content/dam/phacaspc/documents/corporate/publications/chiefpublic-health-officer-reports-state-publichealth-canada/from-risk-resilience-equityapproach-covid-19/cpho-covid-report-eng.pdf 7:34 PM Social Justice PART 3 ◉ Fair distribution of society’s benefits and responsibilities, and focuses on eliminating the root causes of inequities (CNA, 2010) ◉ Leading to degree of equality of opportunity for health that a society provides for the population 7:34 PM ◉ It involves the political, social and economic structures of a society (a choice of a society) 7:34 PM @unsplash Health Equity ◉ Fair distribution of resources for health ◉ The absence of systematic disparities in health between groups with different levels of wealth, power or prestige. ◉ Equity in health is an ethical principle and closely related to human rights principles. 7:34 PM Health Inequity vs. inequality Video from Health Equity Institute https://www.youtube.com/watch ?v=ZPVwgnp3dAc Leopold! COMES BACK TO ETHICS - Avoidable - Unfair - Unjust 7:34 PM Broad Approaches for Health Equity (WHO, 2008) ◉The improvement of daily living conditions ◉Tackling the inequitable distribution of resources ◉Increasing the public’s awareness of, and health professionals’ training in the SDoH as foundational to good health and the structural action necessary to address them Commission on the Social Determinants of Health (2008) Strategies for impacting health equity 7:34 PM Universal Targeted Targeted Universalism Proportional Universalism National Collaborating Centre for Determinants of Health. (2015). Let’s talk…Advocacy for health equity. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University. https://nccdh.ca/images/uploads/Approaches_EN_Final.pdf Do you think nurses should be involved in political struggles like this? “You have to be. That’s where your conscience tells you to go.” Liz James – Street Nurse - BC https://www.youtube.com/watch?v=9Lr-3ntIejw PART 3 19:34 19:34 7:34 PM 7:34 PM https://www.rcdhu.com/wp-content/uploads/2017/03/Image-what-makes-canadians-sick.png 19:34 7:34 PM Structural issues “Many of these (SDoH) can result from even more upstream and insidious structural forces at play. For instance, in the case of First Nations, Inuit and Metis peoples, ongoing challenges from the impacts of colonization, intergenerational trauma from residential schools, systemic racism, jurisdictional ambiguity and lack of self-determination exert a further influence on health and its determinants” ◉ Andermann, A. (2016) p.1 19:34 https://iris.who.int/bitstream/handle/10665/44489/9789241500852_eng.pdf?sequence=1 7:34 PM Impacting on SDoH in practice Major Premises: - Health inequities exist - There are underlying causes of poor health that are at various socioecological levels - To improve health, one needs to think at a community-population level and take health equity into account - Social justice is a guiding principle underlying our professional nursing conduct - All healthcare settings are opportunities to ensure equitable access to quality healthcare and engaging with upstream determinants of health Based on various readings and linked to Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ December 6, 2016 188:E474-E483 7:34 PM 19:34 Raphael, D., Bryant, T., Mikkonen, J. and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. P.14. Retrieved at https://thecanadianfacts.org/ The_Canadian_Facts2nd_ed.pdf 7:34 PM Raphael, D., Bryant, T., Mikkonen, J. and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. INCOME What can be done: ◉ ◉ ◉ 7:34 PM Increasing the minimum wage – living wage policies Boosting assistance levels for those unable to work would provide immediate health benefits for the most disadvantaged Canadians. Improving working conditions and limiting profit making that impacts on employee well-being and income, such as unions 19:34 If you want to look into more of the SDoH ◉ https://thecanadianfacts.org/The_Canadian_F acts-2nd_ed.pdf 7:34 PM 7:34 PM PART 3 1. How does this fit into practice? (Practically) Being a nurse who acts on SDoH - At an individual level - At a practice level - At a community level 7:34 PM 7:34 PM At Patient Level Andermann, A., & CLEAR Collaboration. (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. Canadian Medical Association Journal, cmaj-160177. ◉Ask ○ Sensitivity and caring ○ Food security, violence, discrimination, literacy, immigration issues, etc… ○ ‘Do you ever have difficulty making ends meet at the end of the month?’ ◉Refer and advocate for ○ ○ ○ 7:34 PM “Social Prescribing” ‘Referral to community-based support groups reduced patient anxiety and improved perception of overall health…’ Benefits, tax-credits, etc… 7:34 PM At Practice Level (Institutional) ◉Remove barriers to care – Improve access for vulnerable populations ○ What are barriers to health care? ○ Patient engagement ◉Patient navigators Andermann, A., & CLEAR Collaboration. (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. Canadian Medical Association Journal, cmaj-160177. 7:34 PM Community-Level Andermann, A., & CLEAR Collaboration. (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. Canadian Medical Association Journal, cmaj-160177. ◉Physicians (AND HCP/NURSES) “need not confine their activities to the clinic or hospital but can also serve as effective health advocates and valuable resources for the community” p.4 ◉Partnerships and intersectoral action!! ◉Advocate for social change with clinical experience and research ◉Get involved in community needs assessment-health planning ◉Engagement, empowerment and changing social norms ○ ○ ○ You as a Catalyst for change Cultural safety training Addressing structural racism 7:34 PM CLEAR TOOLKIT Clinical Decision Aid https://www.youtube.com /watch?time_continue=105 &v=1BP_lZjBVJY LEADERSHIP! You! ◉ Nurses pivotal role in health care reform and improving patient safety, access, and quality PART 4 7:34 PM Leadership Defined PART 4 “ Leadership is described in many ways. In the field of public health it relates to the ability of an individual to influence, motivate, and enable others to contribute towards the effectiveness and success of their community and/or the organization in which they work. It involves inspiring people to craft and achieve a vision and goals. Leaders provide mentoring, coaching and recognition. They encourage empowerment, allowing others to lead” PHAC (2010) 7:34 PM General Competencies 1. System Transformation 2.Achieve Results 3.Lead Self 4.Engage Others 5.Develop Coalition Please refer to the document accessible on MyCourses to review the exact competencies. Public Health Leadership Competency Statements 7:34 PM Systems Transformation ◉ Knowledge translation ◉ Understanding of how to guide change ◉ Systems and critical thinking ◉ Innovation/Creativity ◉ Advocate for and guide change ◉ Drive/Motivation ◉ Forward thinking ◉ Adaptation to changing systems @ Google Images 7:34 PM Achieve Results ◉ Use understanding of power and influence and operational expertise to mobilize people to meet strategic goals ◉ Garner support and momentum towards upstream solutions ◉ Personal vision (explicit, clear, and compelling) ◉ Anticipate and take advantage of leadership opportunities ◉ Champion public health principles, actions and interventions ◉ Assess effectiveness and success in terms of population health @ Google Images Lead Self ◉ Abide by ethical codes ◉ Critically examine role within the organization and regulatory systems ◉ Evidence-informed decision making ◉ Lifelong learning and self-development ◉ Accountability ◉ Emotional Intelligence ◉ Self-Aware and reflective ◉ Reflexivity and flexibility in response to criticism 7:34 PM @ Google Images 7:34 PM Engage Others ◉Leverage communication tech for effective communication ◉Credible, responsive, accessible, engender respect, rapport, and trust ◉Transdisciplinary knowledge of multiple professions ◉Tailor communication ◉Empower and enable others by providing strong, unwavering support ◉Build capacity through modelling-mentorship for leadership in others ◉Promote healthy workplace culture ◉Share power (horizontally+vertically) ◉Effective mediation and negotiation skills ◉Recognize and encourage contributions of others Develop Coalition ◉Demonstrate cultural awareness ◉Demonstrate ability to guide health public policy ◉Recognize public health’s role in political influence ◉Ambassadors of quality evidence-informed practice ◉Foster engagement with communities ◉Catalyst for partnership building ◉Promote visibility and awareness of practice ◉Contribute to cross disciplinary understanding of public health practice ◉Leverage partnerships to broaden the scope and impact of public health practice Andermann, A., & CLEAR Collaboration. (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. Canadian Medical Association Journal, cmaj-160177. Baptista, D. R., Wiens, A., Pontarolo, R., Regis, L., Reis, W. C. T., & Correr, C. J. (2016). The chronic care model for type 2 diabetes: a systematic review. Diabetology & metabolic syndrome, 8(1), 7. Betker and Bewick (2016) Financing, Policy, and Politics of Healthcare Delivery. In Textbook Bryant, T., Raphael, D., Schrecker, T., & Labonte, R. (2011). Canada: A land of missed opportunity for addressing the social determinants of health. Health Policy, 101(1), 44-58. Canadian Institute for Health Information (CIHI). (2012d). Health Care in Canada, 2012: A Focus on Wait Times. Retrieved from https://secure.cihi.ca/free_products/HCIC2012-FullReport-ENweb.pdf References CIHI (2017). International Comparisons at CIHI, February 2017. Ottawa, ON: CIHI; Retrieved at https://www.cihi.ca/en/oecd-interactive-toolinternational-comparisons CIHI, (2014) Healthcare priorities in Canada: A Backgrounder. Health Canada (2017) Canada Health Act. Retrieved at http://hc-sc.gc.ca/hcs-sss/medi-assur/cha-lcs/index-eng.php Hill, J., Nielsen, M., & Fox, M. H. (2013). Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill. The Permanente Journal, 17(2), 67. Hitchcock, JE, Schubert, PE, Thomas, SA, Bartfay, W. J. (2010): Community Health Nursing: Caring in Action (1st Canadian Edition). Nelson Education, Toronto, Ontario (ISBN 13:978-0-17-644103-6 and 10: 0-17-644103-4).p.32 Institut de la statistique du Québec (2014). Perspectives démographiques du Québec et des régions, 2011-2061, Québec. p.85 Longpré, C., & Dubois, C. A. (2015). Implementation of integrated services networks in Quebec and nursing practice transformation: convergence or divergence?. BMC health services research, 15(1), 84. Mikkonen J & Raphael D. (2010). Social determinants of health: the Canadian facts. Toronto: York University School of Health Policy and Management MSSS (2017) Gouvernance et origanisation des services. retrieved from http://www.msss.gouv.qc.ca/en/sujets/organisation/en-bref/gouvernanceet-organisation-des-services Raphael, D. (Ed.). (2009). Social determinants of health: Canadian perspectives. Canadian Scholars’ Press. Vedel, I. et al. (2011) Ten years of integrated care: backwards and forwards. The care of the province of Quebec, Canada. International Journal of Integrated Care. Volume 11. ISSN 1568-4156. p.2 Villeneuve, M., & Mildon, B. (2013). " Top 5 in 5": CNA responds to the National Expert Commission. Nursing leadership (Toronto, Ont.), 26(4), 24. Wankah, P., Guillette, M., Dumas, S., Couturier, Y., Gagnon, D., Belzile, L., ... & Breton, M. (2018). Reorganising health and social care in Québec: a journey towards integrating care through mergers. London Journal of Primary Care, 1-6. 19:34 World Health Organization. (2010). A conceptual framework for action on the social determinants of health.