Chronic Disease Prevention and Management

team approach

improvements to PHC were crucial to the modernization of the health care system.

Multi-Jurisdictional Envelope

National Envelope

Aboriginal Envelope

Official Languages Minority Communities Envelope

Provincial-Territorial Envelope

The production of a series of "synthesis reports" was a key element of this dissemination strategy.

Collaborative

Chronic Disease Prevention and Management

Collaborative Care (Vernon Curran, Director, Academic Research and Development, Memorial University); Chronic Disease Prevention and Management (Peter Sargious, Medical Leader, Chronic Disease Management, Calgary Health Region); Information Management and Technology (Denis Protti, Professor, University of Victoria); and Evaluation and Evidence (June Bergman, Assistant Professor, University of Calgary).

Canada's future health system is dependent upon the modernization of primary health care

concepts of chronic disease prevention (CDP) and chronic disease management (CDM) are emerging as important challenges to individuals, health systems, communities and society as a whole.

CDP and CDM are emphasized to different degrees within provincial/territorial health systems-where the emphasis is strong it appears to provide focus for other elements of primary health care, namely collaborative care, information management and technology, and evaluation. Efforts at CDP and CDM do not appear to be coordinated. Canadian jurisdictions will collaborate to create shared CDPM infrastructure-and benefit from national supports that facilitate and reward this. Primary care physician practices were most frequently seen as the focal point around which interdisciplinary CDM should develop.

The experiences related to CDPM in each PHCTF initiative and the findings learned from a collective review have important implications for policy and practice if Canada is to respond strategically to the growing burden of chronic disease.

A convergence of thought and strategy between CDM and CDP agendas, and a clearer articulation of their relevance to modern health systems and civil societies, remain ongoing challenges.

The striking reality, according to the World Health Organization (n.d.), is that the number of people worldwide who will die as a result of chronic diseases in 2006 alone will exceed the population of our country; 35 million deaths, more than 60 per cent of the 58 million deaths worldwide, will be attributable to chronic diseases.

In the Canadian context, the struggle to deal with chronic disease has become one part of a rationale for reforming, renewing and re-energizing primary care and primary health care (PHC). Indeed, improved chronic disease management was one objective of the Primary Health Care Transition Fund (PHCTF), which was announced by the Government of Canada in 2000

Provincial/territorial initiatives where established CDPM strategies predated PHCTF initiatives; Provincial/territorial initiatives where CDPM strategies emerged primarily as a function of, or in parallel with, PHCTF initiatives; and National, multi-jurisdictional, official languages minority communities and Aboriginal initiatives.

The model brings greater attention to the role of public policy and community action in population-based efforts to improve disease management. Using this model, the province leveraged the PHCTF to launch quality improvement collaboratives, bringing together organizations and individual practitioners to improve care for people with specific chronic illnesses: diabetes and congestive heart failure.

Information technology (IT) infrastructure

Physicians

Self-management

Alberta's RHAs had adopted the Chronic Care Model before the PHCTF and in some regions had established scalable infrastructures to support strategies for several chronic diseases

education, self-management and supervised exercise

community-based program

implementation of Health Link Alberta

Delivery system design and community resources were predominant, with early progress in either information technology (IT) or IT development. Self-management support typically represented the third area of activity.

Interviews

Yukon

Nunavut

Saskatchewan and Manitoba

community-focused strategy

home-monitoring solution

Ontario

demonstration, leadership and accreditation projects

PHC models

Emerging Approaches to Chronic Disease Management in PHC

Quebec

Quebec has made Family Medicine Groups (FMGs

An FMG is a new organization composed of family physicians working as a group in close collaboration with nurses, and providing a wide range of services to clients who enrol voluntarily

Nova Scotia

Champions workshops

Diversity and Social Inclusion

Prince Edward Island

development of family health centres

PHC teams.

training programs, in parallel with service delivery redesign

new family physician- home care partnerships, disease-specific programs, and opportunities to share efforts and resources, as well as those involving the delivery of services over geographic and cultural distance.

WHIC initiative

Health Lines

Health Integration Initiative

National Home Care and Primary Health Care Partnership Initiative

Tui'kn (meaning "passage" in Mi'kmaq) Initiative was established to introduce a new way of thinking about health and delivering health care in the five First Nations

Key Learnings

CDP and CDM are emphasized to different degrees within provincial/territorial health systems. When referenced against established models, pre-existing frameworks and strategies were the best predictors of progress in CDPM during the PHCTF. Moreover, CDPM strategies appear to provide focus for other elements of PHC, namely collaborative care, information management and technology, and evaluation. With reference to both established and emergent provincial/territorial strategies, efforts towards CDP and CDM do not appear to be coordinated. They seem to operate parallel to one another. While not explicitly explained in the reports, there are several possible and interrelated considerations for this observation: The Chronic Care Model, while purported to be applicable to preventive care, may have limitations in addressing broader CDP issues. The CDP and CDM communities of interest in Canada have evolved in parallel and without sufficient discourse to create integrated approaches at a project level. CDP may indeed have sufficiently different methodologies and societal and cultural undertones as to require a distinct strategic effort, even if under a broad banner of CDPM. Given the appropriate support, Canadian jurisdictions will collaborate to create shared CDPM infrastructure. This was evident in the successes of the multi-jurisdictional and Aboriginal initiatives and also in spontaneous exchanges that occurred during the PHCTF. It would appear that these collaborations resulted in considerable leverage and (or) mutual benefit. Infrastructures such as health lines and IT represent specific opportunities for ongoing provincial/territorial collaboration and federal support. There was less indication that investments in disease-specific initiatives created similar motivation for collaboration. Arguably, primary care physician practices were most frequently seen as the focal point around which interdisciplinary CDM should develop. Furthermore, the interprofessional relationship most studied and sought was that between physician and nurse. Perhaps for the reasons described in point two above, the focal point for CDP was more varied; sometimes referenced as a function of the relationship between a citizen and his or her care providers, sometimes as a function of the relationship between a citizen and his or her community. Regardless of concerns raised about their perceived comfort, capability and support in CDPM activities, primary care physician engagement, leadership or championship was often described as a foundation for success within the PHCTF initiatives. Once engaged, they are amenable to new mechanisms of care delivery and new ways of relating to patients and other health professionals. Conversely, a lack or slowness of physician engagement was a harbinger of difficulties ahead. Provincial/territorial initiatives that recognized a need to engage primary care physicians not just as necessary participants but necessary leaders in CDM could be described as having achieved broader and more sustainable success. This recognition was typically reflected in the pursuit of: 1) new collaborative approaches to process and practice redesign; 2) new infrastructure for information management and communication; and 3) new models of compensation (or, at a minimum, new fee-for-service options), to encourage interdisciplinary CDM or CDP activity among community physicians. As suggested by the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians (Schoen et al., 2006), considerable opportunity remains for improvement in these areas.

recognizing chronic disease as a national epidemic and global crisis;

formal integrated responsibility for CDM and CDP strategies and operations

determination at all levels of government (

medical aspects of CDM are logically within the jurisdiction of the health system, CDP and non-medical approaches to CDM require multisectoral engagement, responsibility and accountability;

Collaboration across communities of interest in CDM and CDP, with both enlightened leadership and integrated theoretical models capturing the points of intersection and divergence between these activities; and

Integrated theoretical models to capture a common language for discourse and extend to include methodologies outside the reach of current models

and

to address the challenge of chronic disease-this includes not only a willingness to "mirror" local infrastructures created elsewhere but to co-develop shared infrastructure in areas such as conceptual/strategic models of CDPM and IT standards.

Collaborative approaches to process and practice redesign; Development or implementation of IT infrastructure for information management and communication; and Study of new models for contracting and compensating health care professionals.

, Alberta has developed innovative models in children's mental health, and has emphasized health promotion and disease prevention