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Une enquete montre que la plupart des directeurs des soins souhaitent prendre une part, de plus en plus importante, dans la strategie des etablissements de sante. Ils presentent en effet pour cette responsabilite des atouts particuliers : un “professionnalisme hybride” avec l’appartenance aux professions paramedicales et une expertise dans l’accompagnement des organisations.

L’essor des postes de coordonnateurs offre aux infirmiers de nouvelles opportunités de carrière et de formation. Il pourrait aussi favoriser une montée en qualification de la profession et contribuer à transformer les relations entre les acteurs du soin.

The concept of integrated services delivery, although dating from the 1990s, has only recently appeared in French public health policy. To clarify the concept and its adaptation to the reality of the French systems of healthcare and social services, the French Society of Geriatrics and Gerontology established an interdisciplinary working group. This article reports that group's findings according to three axes: the definition of integration, the objectives of this organizational approach and the means needed to achieve them. Analysis of the literature indicated that integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, finance, interventions and returns on the latter. Indeed, this sharing is the ultimate proof of evolution towards integration. In the second part of the position paper, its authors have developed arguments that could lead professionals and non-professional caregivers to adopt integrated care as an answer to their aspirations. Policy-maker perspectives and politicians are also analyzed. Bearing in mind that integrated care necessarily will always involve a human component which may find expression during individual case-management; relations between integration and case managements are clarified. Finally, lessons learned from national and international experiments are examined. Results suggest that integrated care must to be accompanied by a local pilot. Results of recent experiments have shown that it is possible to initiate a dynamic towards integrated care in France and hence join the international movement towards adapting our healthcare systems to new challenges.

International audience; The concept of integrated services delivery, although dating from the 1990s, has only recently appeared in the French public health policy. To clarify the concept and its adaptation to the reality of the French systems of healthcare and social services, the French Society of Geriatrics and Gerontology established an interdisciplinary working group. This article reports the group's findings according to three axes: the definition of integration, the objectives of this organizational approach and the means needed to achieve them. Analysis of the literature indicated that integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, finance, interventions and feed-back on the latter. Indeed, this sharing is the ultimate proof of evolution towards integration. In this first part of the position paper, its authors analyzed integrated care definitions used in international literature in view of designing the most important components of integrated care. The examination of this concept must be articulated with the idea of "coordination" which has been the cornerstone of the majority of public policies applied to the field of geriatrics and gerontology since the 1960s in France. The components of integrated care highlight that it is an ambitious process leading to real systemic modification. The authors also have proposed to open up a dialogue between citizens' aspirations and integrated care objectives with the aim to verify that the latter respond to the needs as expressed by the targeted group.; Le concept d’intégration des soins et des services, bien que datant des années 1990 n’est que récemment apparu dans les politiques publiques en France. Afin de clarifier le concept et son adaptation à la réalité du système de soins et de services français, la Société française de gériatrie et de gérontologie a mandaté un groupe de travail interdisciplinaire. Les travaux de ce groupe sont synthétisés selon trois axes : la définition de l’intégration, les objectifs poursuivis par cette orientation organisationnelle et les moyens à mettre en œuvre. Il se dégage de l’analyse de la littérature que l’intégration est un processus qui vise à dépasser les frontières de la fragmentation des systèmes de services répondant à des populations en situation de vulnérabilité. Ce processus nécessite une réflexion multi-niveau, notamment sur la façon dont les politiques publiques et les systèmes de financement doivent être modifiés. Ainsi, à tous les niveaux concernés, doit se développer un partage de processus, d’outils, de moyens, de finances, d’actions et de retour sur ces actions. C’est ce partage qui est la preuve de l’évolution vers l’intégration. Dans cette première partie du rapport de leurs travaux, les auteurs ont analysé les définitions les plus utilisées dans la littérature internationale concernant le concept d’intégration. De cette comparaison de définition ils font ressortir les traits les plus saillants de l’intégration. Ce concept doit s’articuler avec celui de “coordination” qui a prévalu dans la conduite de la majorité des politiques publiques touchant le champ gérontologique depuis les années 1960 en France. Les caractéristiques de l’intégration permettent de saisir qu’il s’agit d’un processus ambitieux permettant une réelle modification systémique. Les auteurs ont mis en dialogue les aspirations des citoyens avec les objectifs de l’intégration afin de vérifier que ces derniers répondent bien à des besoins exprimés par les personnes à qui elle s’adresse.

Le concept d’integration des soins et des services, bien que datant des annees 90, n’est que recemment apparu dans les politiques publiques en France. Ce concept doit s’articuler avec celui de « coordination » qui a prevalu dans la conduite de la majorite des politiques publiques touchant le champ gerontologique depuis les annees 60 en France. Afin de clarifier le concept et son adaptation a la realite du systeme de soins et de services francais, la Societe francaise de geriatrie et de gerontologie a mandate un groupe de travail interdisciplinaire. Les travaux de ce groupe sont synthetises dans cet article.

Introduction: Despite continuing efforts by national and local policy-makers, the French health and social care system still remains fragmented, often resulting in many problems for the users, their family, as well as the local managers and providers of care (Bloch, 2013; Bloch and Henaut, 2014). Most of the recent attempts to overcome fragmentation regarding elderly care took the form of pilot projects. In this paper, based on literature and ethnographic materials, we argue that integration has been difficult to achieve because pilots have been launched, at the national level, by siloed and competing administrations, and circumscribed, on sites, to either health or social care providers. However, new trends in policy piloting seem to be able to change the course of that story. First, some pilot project managers have been able to work with local managers and care providers in order to achieve what we call “integrative piloting”. Second, the rise of a social movement among integrated care pilot project managers is impacting the development of integrated care policies both at the local and national levels. Methods: The paper is based on literature and ethnographic materials. First, complementing the work of Somme and de Stampa (2011), we traced the history of coordination and integration policies for the elderly in France thanks to a systematic literature review of more than 300 documents produced by scholars or policy-makers. Second, we conducted an in-depth analysis of three major coordination schemes that have been implemented across the country after several years of piloting: _CLIC, Reseaux_ and _MAIA_. Interviews and observations have been done in four sites (center of Paris, North East suburb of Paris, Marseille, Ile de la Reunion). Interviews focused on the work of pilot project managers and front-line professionals involved in coordination schemes (N=45), local policy makers (N=15), and leaders of newly created associations or networks related to the different pilots (N=4). Finally, we attended assemblies and training sessions arranged for the managers of the three coordination schemes. Results: At the level of national policy-makers, each administration (social affairs, health care, long term care, and social security) tried to overcome fragmentation by developing its own coordination scheme. The lack of interaction and the on-going competition between administrations, along with the inability to conduct or use public policy evaluations, resulted at the local level in a never-ending struggle against fragmentation. The paper presents the complex web of competing and overlapping coordination schemes in the settings that have been investigated. While most professionals had a limited view of health and social care providers for dependent elderly persons, and of coordination schemes, some project managers succeeded in developing local integration by implementing what we call “integrative piloting”. They got other managers and providers on board thanks to the display of relational and entrepreneurial skills. They also took advantage of calls for applications offered by different administrations to channel new funds and build innovative collaborative schemes. In addition, our study shows the increasing role of the newly created associations and networks of the project managers who are piloting and managing coordination schemes in the development of best practice guides. They are in the process of combining their efforts in order to attract the attention of national policy-makers on several “local success stories”. Discussion: Centrifugal forces take place both at the national and local levels. Because of the lack of learning process, policy-makers have been creating layers of coordination schemes. However, in-depth case studies reveal that it is possible to redesign the different pilots depending on the local context and convert the layers into integrative schemes. The role of the newly created associations of project managers as part of a new centripetal force can be discussed. Conclusion: There is no doubt that national administrations should intervene in a more coordinated way. Moreover, on the face of it, the management of the complexity of the health and social care system can also benefit from local initiatives, and from meso-level organizations such as the association of networks of coordination schemes managers. Only time will tell if these new trends will become perennial. References: 1- Bloch M.-A. La fragmentation du systeme de sante et d’aide pour les personnes âgees, ADSP (Actualite et dossier en sante publique)2013; 85, 30-35. [in french] 2- Bloch M.-A. et Henaut L. Coordination et parcours. La dynamique du monde sanitaire, social et medico-social, Paris, Dunod 2014. 3- Somme D. et Stampa M. de Ten years of integrated care for the older in France, International Journal of Integrated Care, 11, Special 10th Anniversary Edition 2011.

In response to increasing care needs, the development of elderly care systems has become a prominent policy concern across the OECD. Since the beginning of the 1990s, the increasing economic constraints led to the rise of policies that focus on the improvement of “coordination” and “integration” of administrations and services – in other words, policies that aim at reducing the fragmentation of health and social care system. As a result, a growing number of studies focus on innovative integrated care schemes and their transferability from one national context to another. Yet they do not systematically investigate the political, organizational, cultural and societal contexts in which they have emerged neither do they link them to the diverse conceptions of integration or coordination carried by the multiple actors concerned. In this paper, we identified three policy-making mechanisms underpinning integration policies at both national and local levels. Theory/Methods : The POLIA-INLOVE comparative research investigates integration/coordination policies in three European countries – France, Sweden and UK. Its analytical framework borrows from sociology, public policy analysis and management studies. Based on a qualitative and diachronic perspective, not presupposing the existence of any integration/coordination policy in the countries studied, it focuses on the understanding of whether, when and how the need for professional, institutional and organizational integration/coordination came to be formulated. Our approach seeks to deconstruct the meaning of integration and coordination policies led in the three countries, and to understand their institutional, organisational and historical contexts. This paper presents the first results of a literature review and an empirical survey by semi-directive interviews led since 2013 in France (n=27), Sweden (n=22) and the UK (n=28). It covers two levels: interviews with national experts at the macro level of policies developed and implemented nationally and with actors at the micro level concerning specific schemes implemented locally, to take into account the organizational particularities in each of the countries and on chosen territories Results : The analysis of the policies in France, Sweden and UK shows the impact of both the national and the territorial contexts, which varies from one country to the other. It leads us to identify three different policy-making processes towards coordination/integration. We provisionally named them “layers”, “chains” and “lineages”. These logics are unequally shared out between the three countries: the layering process can be identified as a dominant trend in France whereas the chaining logic is dominant in Sweden. The lineage metaphor, finally, looks more appropriate when it comes to analyze the history of attempts for reducing fragmentation in England. Yet, further analysis including concrete solutions experimented on both national and local levels shows that there come to be a mix of logics mobilized in each concrete situation. Thus, the different logics are not directly opposed and they can be expected to work together Discussion : Qualitative comparison raises significant challenges due to the risk of comparing schemes or elements which are not comparable, particularly for locally implemented models developed in specific territorial contexts, unless one focus on the learning and adaptation processes. Secondly, comparison between countries representing different welfare models runs the risk of reducing the observed outcomes to the same variables used for the identification of the welfare models. By putting the accent on identifying the underpinning logics of integration/coordination policies in the three countries rather than running a systematic comparison of their content, we address these challenges in two ways: - The three logics identified articulate both macro and micro analysis since they are based on the identification of the mechanisms underpinning both national policies and locally implemented measures. -The three logics are analyzed in relation to the different welfare state models and to the wider political projects they belong to. Conclusion : The next step of the research consists in identifying common cross-cutting issues in at least two of the three countries studied: -The impact of the political variable on the orientation and the content of integration/coordination policies; -Interactions between local and national levels as opportunities and constraints for integration; -The issue of New Public Management in the integration/coordination process Taken as basis for comparison, these issues can inform aspects of processes of integration/coordination that are often analyzed in one single national/local context.

International audience; Cet article porte un regard sociologique sur la catégorie « fragilité des personnes âgées », qui prend une place de plus en plus importante dans les discours sur l’autonomie en France. À partir d’un travail d’analyse bibliographique complété d’observations d’événements scientifiques et institutionnels, nous analysons d’abord les différentes acceptions de cette catégorie (approche biomédicale, approche en matière de vulnérabilité, approche populationnelle), ainsi que ses ambitions plus transversales en matière de prévention de la perte d’autonomie et d’intégration des services. Nous saisissons ensuite les actions sur la fragilité à la lumière d’entretiens et observations avec des professionnels de deux territoires.La fragilité des personnes âgées émerge comme un motif d’action publique, dont le succès provient autant de la plasticité de son contenu – permettant d’engager une diversité d’acteurs au sein des organisations du champ de l’autonomie – que de ses implications normatives. Pour autant, les actions sur la fragilité sont sérieusement mises à l’épreuve de la fragmentation de ce domaine de l’action publique, dans lequel l’articulation des différentes interventions est loin d’aller de soi.

The rapid rise in the number of coordinator posts offers nurses new career and training opportunities. It could also favour a rise in skill levels within the profession and help to transform relations between health care professionals.

Introduction: The increasing number of people in chronic conditions requires not only a growing number of diverse care and support services, but also a better articulation between the different providers. To reduce the fragmentation of the health care system, policy makers, professionals, and family and user-led organizations, are engaged in a permanent process of innovation and cooperation. Because the improvement of integrated care relies entirely on that collective dynamics, the latter has to be better understood. Aims: Approach integrated care schemes through their life cycle, offer an interactive model explaining the dynamics of innovation, and identify the success factors that facilitate integration work in France. Results: Comparing seven different integrated care schemes created in France over the past two decades, both for vulnerable elderly and for adults with disabilities, shows that their development follows a similar pattern – what we call the life cycle of integrated care schemes – made of three to four phases: emergence, building up, routine, and eventually disappearance. All along the process, local initiatives, usually conducted by pioneer physicians or family and user-led organizations, face national public policy agenda. Interactions occur through four key processes initiated by national-level policy makers: experimentation, assessment, conceptualization, and generalization. More specifically, these processes are meta-processes because they are fuelling schemes’ life cycles which are themselves organizational processes. Depending on the scheme you consider, the four meta-processes occured neither in the same order nor at the same pace. Hence the comparison helps us understand the factors that may restrict or facilitate the effective implementation of integration work. Finally, the in-depth study we realized on an emergent scheme devoted to the management of people with rare diseases’ care pathways, reveals the reciprocal learning and prescription process between local political entrepreneurs and policy makers working at multiple levels. Conclusions: Innovation is neither the work of a few pioneers nor the one of national policy makers, but a collective and interactive dynamics. The continuity of public funding is crucial in the process, as well as the existence of a resource project team at the national level in order to ensure equal treatment throughout the country.

Introduction: The concept of integration, although dating from the 1990s, has only recently appeared in French public health policy. It must be linked with “coordination”, which is the base of most French public policies applied to geriatrics since the 1960s. Herein, we report the French Society of Geriatrics and Gerontology working group’s findings according to three axes: definition of integration, objectives of this organisational approach and the means needed to achieve them. Discussion: Integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, financing, interventions and action-reports on the latter. Integration must to be accompanied by a local dedicated professional (the “pilot”). Results of recent experiments showed that it is possible to implement integrative dynamics in France.

International audience; L’accroissement du nombre de personnes âgées, handicapées ou atteintes de maladies chroniques, rend nécessaire le développement et la diversification des soins et des services, mais demande aussi une meilleure coordination des interventions. Pour lutter contre les différents cloisonnements du système de santé et d’aide, les pouvoirs publics, les professionnels et les associations de familles et d’usagers sont engagés dans un processus permanent d’innovation et de coopération à l’origine de la dynamique de l’ensemble du monde sanitaire, social et médico-social. Cet ouvrage retrace l’histoire de la structuration de la coordination en France dans plusieurs domaines d’intervention (gérontologie, santé mentale, handicap, cancer, maladies rares, accident cérébral), ainsi que l’apparition récente de la notion de parcours dans l’espace public. Il propose une analyse critique des politiques conduites en matière de coordination, et tente d’expliquer la persistance des dysfonctionnements observés. À partir d’enquêtes réalisées sur plusieurs territoires, les facteurs de succès pour la mise en place de dispositifs de coordination pérennes sont ensuite mis en évidence. L’innovation se révèle être le produit des interactions entre initiatives locales et directives nationales. Enfin, l’ouvrage propose une typologie des nouveaux professionnels de la coordination (gestionnaires de cas, pilotes, référents, médecins coordonnateurs, chargés de mission…) et souligne notamment le rôle clé joué par les cadres intermédiaires des organisations sanitaires, sociales et médico-sociales. (4e de couv.)________________________________________________________________________________________________Sommaire de l'ouvrage :La coordination dans les secteurs sanitaire, médico-social et social : l’objet de l’ouvrage. Un cadrage selon trois axes problématiques. De la coordination aux parcours: la construction d'un enjeu de santé publique. La structuration de la coordination : des histoires différentes selon les champs d’intervention. La persistance des dysfonctionnements : un essai de diagnostic. De la coordination aux parcours : un changement de paradigme. Les mots et les maux de la coordination. Sur le terrain : la dynamique des expérimentations et des coopérations. Les innovations locales à l’épreuve des politiques publiques, et réciproquement. Mettre en œuvre la coopération : un processus d’ajustement continu. De l’expérimentation au prototype : vers l’innovation intégrative. Pour une innovation solidaire. Les professionnels de la coordination: nouvelles fonctions, nouveaux défis. Trois figures de coordonnateurs interdépendants pour accompagner les personnes dans la gestion de leur parcours. De nouvelles professionnalités pour accompagner le changement. Au-delà des luttes de juridictions : une coordination distribuée. Conclusion et perspectives. Un domaine en complexité croissante. Des pistes d’amélioration pour le futur. Les limites de notre ouvrage et les perspectives de recherche.

A la suite d'un appel à projet lancé par la Fondation Paul Bennetot en avril 2010, le Centre de Gestion Scientifique de Mines-ParisTech a réalisé une étude sur la coordination dans le champ sanitaire et médico-social. Le rapport remis à la Fondation en janvier 2011, propose un état des connaissances internationales sur le sujet, une analyse inédite de la structuration de la coordination en France, et des solutions qui mériteraient d'être développées en termes de dispositifs et de compétences professionnelles. Le présent document propose une synthèse des résultats de l'étude en 6 points : - 1. Problématique et méthodologie - 2. Le rôle des pouvoirs publics : historique et diagnostic - 3. Sur le terrain : la dynamique des expérimentations - 4. Coordonner les structures decoordination : les méta-réseaux - 5. Les professionnels de la coordination : nouvelles fonctions,nouveaux défis - 6. Perspectives et préconisations.

La problematique des aidants, de l’entourage ou professionnels, prend ces dernieres annees de plus en plus d’importance. Les principales raisons sont le vieillissement de la population, l’augmentation des contraintes economiques sur le systeme de sante, le souci de mieux prendre en compte les besoins des personnes qui necessitent une aide a l’autonomie et de leur entourage et la necessite de proposer des reponses adaptees. Dans cet article nous proposons un panorama general des principaux themes de recherche dans ce domaine, en nous interessant a la fois aux proches aidants et aux aidants professionnels, etant donne leur interdependance en termes de complementarite et de cooperation. Nous presentons les differentes methodologies et disciplines mobilisees en remarquant comment, de maniere fertile, elles peuvent se combiner et faire emerger un nouveau champ de recherche, autant tourne vers le developpement de la connaissance que vers l’identification et l’evaluation de nouvelles solutions, en lien avec les pouvoirs publics, les professionnels et les associations d’usagers et de familles.

International audience; Enteric infections, including bacterium-induced diarrhoeal diseases, represent a major health burden worldwide. In developed countries, infectious diarrhoea contributes primarily to morbidity. It remains the second leading cause of death in children below 5 years of age living in the developing world (Cheng et al. 2005; You et al. 2010). It is anticipated that improved living conditions will contribute to diminish the transmission of enteric pathogens and lower the incidence of enteric diseases. In the meantime, the introduction of vaccines could play an active part in reducing the vulnerability of the target populations to the predominant enteric pathogens. Along this line, Shigella, ETEC, cholera, and typhoid fever were identified by WHO since the early 1990s as the highest bacterial disease priorities for the development of new or improved enteric vaccines. Substantial progress was made (Levine 2006). In this context, polysaccharide-based parenteral vaccines have been investigated with some success. The licensure of the purified capsular Vi polysaccharide against typhoid fever was an important achievement, especially since recent evidence of herd protection conferred by the vaccine has highlighted the benefit of large-scale use in endemic countries (Khan et al. 2010). Moreover, encouraging investigational studies on a Vi polysaccharide–protein conjugate vaccine, which could be introduced into the infant immunization schedule, were reported (Canh et al. 2004; Cui et al. 2010).