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La santé en France, un système en marche ! : la complexité au service des soins de proximité et des maladies chroniques

Abstract : The object of this thesis is the complexity concept, applied in the healthcare sector. Three major interconnected subjects were selected to study the appropriateness of this approach, its added value, and its application: chronic diseases, integration-coordination of care, and primary care. Four parts design the thesis: The 1st part introduces complexity concept and its appropriateness in the healthcare sector. The literature review and foreign experiences have approved that healthcare system is vital and a complex adaptive system (CAS): the healthcare system is a chain of effects: patient and community - microsystem - macro organization - environment (legal, ethical, financial, social, and regulatory, etc.). This domino effect and the dominoes are essentials. The microsystems has a pivotal role in this chain. They are the smallest replicable unit, at the sharp end with the population. They viewed as the micro-engines that generated quality and value for users, as the vital organs that linked users through the actions taken by front-line service providers at what has been called the "sharp end". The 2nd part brings the (CAS) closer to chronic diseases. Values, actors, patients, duration, care delivery, practices and medicine are undergoing changes and require a change in behavior. Understanding and studying current system agent patterns and their relationships supply a first ethical response: it all begins with this patient dependence feeling and the "patient-physician relationship pattern review. A domino effect has triggered that redesign the entire healthcare system. Empowerment is essential for a long micro-changes'process (i) of patients (to accept, to live and to self-manage his disease) and (ii) care teams (including physicians) to review their relationship with the patient and their mutual relationships. These micro-changes took place in the microsystem. The 3rd part of the thesis brings the (CAS) closer to the coordination issues and integration of care, particularly for chronic diseases. Coordination of complex patient case has often concerned the French legislator which recognizes and funds dedicated health network bodies. According to a recognized model, this part studies the factors of successful integration (coordination) and realizes that the (CAS) is inescapable: the patient pathway occurs and then orchestrated in the microsystem. It explains the health network's mixed results: these bodies cannot be (CAS). The outlined results of two observational studies using qualitative methods, carried out on the main health network components -the inpatient, the outpatient: (i) the meaningful existence of an inpatient (CAS), at varying vitality.The highest vital microsystem creates abvious generative interactions with all actors, inpatient, outpatient. Open to share and cooperate, it actively contributes in complex case management. (ii) mistrust and competition, between several outpatient actors, hinder any primary (CAS), for mutual generative, constructive relationship with inpatient microsystems. The 4th part brings the (CAS) closer to "territorial primary care platforms" (PTA), created by French legislator in 2016. This part outlines the steps to emerge a primary (CAS). It provides final answers to current questions related to the relationship health network- (PTA), to evaluation and improvement ways of such primary (CAS). The funding integration seem essential to succeed this new challenge.
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Submitted on : Wednesday, April 8, 2020 - 11:35:11 AM
Last modification on : Tuesday, May 11, 2021 - 8:21:54 PM


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  • HAL Id : tel-02536584, version 1


Karim Victor Laaribi. La santé en France, un système en marche ! : la complexité au service des soins de proximité et des maladies chroniques. Ethique. Université Sorbonne Paris Cité, 2017. Français. ⟨NNT : 2017USPCB265⟩. ⟨tel-02536584⟩



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