Implementing the Chronic Disease Prevention Management Framework

1. Implementing the Chronic Disease
Prevention and Management Framework
Moving from Operational Independence to Shared Care
Michelle Goulbourne
Global Perspectives on Chronic Disease Prevention and Management
2007 Conference Calgary, Alberta
October 29, 2007

2. DISCLOSURE:
I have no real or potential conflict to disclose.

3. Overview
 Chronic Disease in the Canadian Context
 Implementing the Chronic Disease Prevention and Management Framework
in Canada
 Regionalization
 Discontinuities in Care
 Impact on Performance
 Implementation Experiences
 Current State
 Future State
 The Road Towards Shared Care
 Conceptual Model
 Operational Model
 Innovations Across Canada

4. Chronic Disease in the Canadian Context
 In Canada chronic disease is a major Percent of adults with at least
cause of death and disability. one of six chronic conditions*
 The leading four preventable diseases
cardiovascular, cancer, respiratory and
diabetes, cost an estimated 45 billion
dollars annually.
 Two out of three adult Canadians have
one or more of the major risk factors
associated with a preventable chronic
disease.
(MOHLTC 2007)
*Hypertension, heart disease, diabetes, arthritis, lung problems,
and depression
2004 Commonwealth Fund International Health Policy Survey

5. Chronic Disease Prevention and Management
Framework Goals
 Nationally, Chronic Disease Prevention Management policy frameworks
have been based on the Chronic Care Model developed by the Group
Health McColl Institute for Healthcare Innovation in Seattle (Wagner et al. 2001).
 Expanded versions of this model have been adopted because of their
focus on health promotion and a coordinated systems approach to disease
prevention and management are thought to provide important
opportunities for:
1. Reducing care discontinuities
2. Increasing prevention behaviors
3. Improving population health
4. Reducing cost
 Implementing the CDPM framework for such long lasting sustainable
improvements is a challenge that requires a comprehensive system-wide,
multi-leveled approach to change.

6. Regional Deployment of the CDPM Framework
Regional deployment of the CDPM
framework requires that within each
region, local health care organizations:
 Make systematic efforts to improve
prevention and management of chronic
disease.
 Engage in delivery system design with
a focus on prevention, improved access,
continuity of care and flow through the
system.
 Facilitate personal skills and self-management support among the population by
empowering individuals to build skills for healthy living and coping with disease.
 Develop healthy public policy and supportive environments by creating and
implementing policies that will improve individual and population health and address
inequities.
(MOHLTC 2007)

7. Implementing the CDPM Framework
Literatures on strategy and organizational improvement suggest that we are not
so good at implementing what we design or at developing the new capabilities
the organization needs to survive and thrive – hence the need to become better
at designing and implementing organizations that can carry out our purposes
and provide settings where we can develop and thrive (Mohrman 2007).

8. Voices From The Field – Structural Issues
 This CDPM framework, while insightful, shares no concrete information
organizations can draw upon which shows them how they can build bridges
to integrate organizational silos.
“Chronic disease programs in state public health agencies across the United States are
increasingly taking action to integrate activities across single-disease program lines.
The perceived benefits of program integration are the motivating force behind these
actions, but there is little documentation about how to integrate programs, what the
benefits are to program integration, and what barriers exist (Yach et al. 2004, p.
2616).”

9. Voices From The Field – Process Issues
 Implementation is described as being a difficult process.
“Although the evidence base for some of these elements is incomplete, it is clearly a
comprehensive and promising way to conceptualize a path to better care for people
with chronic conditions. The problem is that we have no complete examples of an
implemented CCM and no specifics about the best care changes to make or the most
effective change process to use for implementing them…there is little or no information
about the relationship between the presence of CCM elements and indicators of care
quality (Solberg et al. 2006, p.311).”

10. Voices From The Field – Governance Issues
The Reality: Divergent Values and Independent Action
When organizations
have been tasked with  Individual agencies may demonstrate territoriality and
moving from single perceive a “loss of glory” (reluctance to share credit for
achievements).
disease to multiple
chronic disease  Resource costs involved in creating partnerships inhibit
frameworks in the collaboration. Fear that collaborations may impact on
absence of a central independent fundraising activities.
coordinating structure,  Problems integrating programs as each program may be
they do not always governed by different policies, service terms and day-to
respond to to-day operations - creating a “silo effect”.
environmental
 Difficulties maintaining smaller or underfunded programs
uncertainty by engaging when they are integrated with established fully funded
in collaborations. programs.
(Robinson, Farmer, Elliot and Eyles 2007)

11. Summary of CDPM Implementation Issues
 Governance
 Leadership to help build and support inter-organizational bridges.
 Structure
 Complete examples about implemented CDPM frameworks
 Evidence to support all parts of the framework
 Best, most effective, care changes
 Relationship between CDPM elements and quality indicators
 Process
 How to integrate programs and services across diseases
 How to build bridges across organizational silos

12. Regionalization
Across Canada, provincial efforts have paralleled global approaches in
trying to deal with health system uncertainty by establishing regional
care delivery organizations to create a more integrated, coordinated
and patient oriented healthcare delivery system.

13. Healthcare Regionalization in Canada
 In Canada Regional Health Authorities (RHA‟s) exist as autonomous organizations.
 Relationships with health care providers are characterized by accountability
agreements.
 Are responsible for healthcare administration, planning and coordination within
specific geographic regions.
 Have appointed or elected boards and are responsible for the funding and
delivery of community and institutional programs and services such as CDPM
within their regions (Kirby 2002).
 Governance models under which provincial RHAs operate varies across provinces.
 Within each province, the level of centralization may have implications for CDPM
activities and performance outcomes.

14. Incomplete Integration and Coordination
 Despite sharing similar objectives, provincial health system transformations have
produced RHAs that differ in size, structure, scope of responsibility and
accountabilities .
 While all RHAs manage hospital services, only some RHAs oversee laboratory
services, long-term care, home care and a variety of other services.
 No provincial authority contracts physician services, manage prescription drug
programs or cancer services.
 That these important care partners remain under the jurisdiction of provincial
and territorial portfolios has implications for provision of integrated service
delivery and coordinated CDPM care in the community.
 Considerable local level variation exists in the way CDPM is implemented and the
levels of success attained.

15. Results  Discontinuities in CDPM
CDPM progress is hampered by care discontinuities associated with poor system
integration and coordination.
1. Gaps in governance impede system capability to develop integrative policies
and local level partnerships across hospitals, physician and community health
stakeholders that will improve access to care, increase quality and health
service delivery.
2. Lack of technological integration results in a loss of information about patient
and family characteristics and histories.
3. Quality gaps in service integration and coordination remove opportunities for
communicative interactions and knowledge transfer between patients, families
and specific providers.
The impact of these discontinuities is evident
in our performance on global quality measures.

16. Performance
• Overall Ranking
• Information Technology
• Disease Management
• Physician Integration

17. Country Rankings
Overall Performance Ranking* 1.0-2.66
2.67-4.33
4.34-6.0
NEW UNITED UNITED
SICKER ADULTS AUSTRALIA CANADA GERMANY ZEALAND KINGDOM STATES
OVERALL RANKING (2007) 3.5 5 2 3.5 1 6
Quality Care 4 6 2.5 2.5 1 5
Right Care 5 6 3 4 2 1
Safe Care 4 5 1 3 2 6
Coordinated Care 3 6 4 2 1 5
Patient-Centered Care 3 6 2 1 4 5
Access 3 5 1 2 4 6
Efficiency 4 5 3 2 1 6
Equity 2 5 4 3 1 6
Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6
Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102
* 2003 Data Source: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the
Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health P olicy
Survey of Primary Care Physicians, and the Commonwealth Fund Commission on a High Performance Health System National Scorecard.

18. Technology

19. Public Investment per Capita in
Health Information Technology (HIT) as of 2005
$192.79
$200
$150
$100
$50 $31.85
$21.20
$4.93 $0.43
$0
United Canada Germany Australia United
Kingdom States
Source: The Commonwealth Fund, calculated from Anderson, G.F., Frogner, B., Johns, R.A., and Reinhardt, U.
“Health Care Spending and Use of Information Technology in OECD Countries,” Health Affairs, 2006.

20. Primary Care Doctors Use of Electronic Patient
Medical Records, 2006
Percent of physicians
98
100 92 89
79
75
50 42
28
23
25
0
NET NZ UK AUS GER US CAN
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

21. Primary Care Practices with Advanced
Information Capacity, 2006
Percent reporting 7 or more out of 14 functions*
100
87 83
75 72
59
50
32
25 19
8
0
NZ UK AUS NET GER US CAN
*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions,
access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis,
medications, patients due for care.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

22. Practice Use of Electronic Technology, 2006
Percent reporting
AUS CAN GER NET NZ UK US
routine use of:
Electronic ordering
65 8 27 5 62 20 22
of tests
Electronic
prescribing of 81 11 59 85 78 55 20
medication
Electronic access to
76 27 34 78 90 84 48
patients‟ test results
Electronic access to
patients‟ hospital 12 15 7 11 44 19 40
records
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

23. Prevention

24. Patient Reports on Reminders for Preventive
Care, 2004
Percent of adults receiving preventive care reminders
75
49 50
50 44
37 38
25
0
AUS CAN NZ UK US
2004 Commonwealth Fund International Health Policy Survey

25. Physicians Reporting Routinely Sending Patients
Reminder Preventive/Follow-Up Care Notice, 2006
Percent of physicians
Yes, using a manual system Yes, using a computerized system
100
5
14
75 18
16
50 93
24 83
65 61 32
25
20 28
18
0 8
AUS CAN GER NET NZ UK US
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

26. Disease Management

27. Sicker Adults Given Self-Management Plan, 2005
Percent of sicker adults with chronic conditions* whose
doctor gave plan to manage care at home
100
65
58 56
50
50 45
37
0
CAN US NZ AUS UK GER
* Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma,
emphysema, etc.), or depression.
Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 27

28. Received Recommended Care
for Chronic Condition, Sicker Adults, 2005
Percent received
AUS CAN GER NZ UK US
recommended care:
Hypertension* 78 85 91 77 72 85
Diabetes** 41 38 55 40 58 56
* Blood pressure and cholesterol checked.
** Hemoglobin A1c and cholesterol checked, and feet and eyes examined.
2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

29. Physician Integration

30. Doctors‟ Reports of Care Coordination Problems,
2006
Percent saying their patients
“often/ sometimes” AUS CAN GER NET NZ UK US
experienced:
Records or clinical information
not available at time of 28 42 11 16 28 36 40
appointment
Tests/procedures repeated
10 20 5 7 14 27 16
because findings unavailable
Problems because care was not
well coordinated across 39 46 22 47 49 65 37
sites/providers
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

31. Percent of Doctors Reporting Practice Is Well
Prepared to Care for Chronic Diseases, 2006
Percent of physicians
reporting “well AUS CAN GER NET NZ UK US
prepared”:
Patients with multiple
69 55 93 75 67 76 68
chronic diseases
Patients with mental
50 40 70 65 48 55 37
health problems
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

32. We must do better.
We can do better.

33. Implementation Experiences - Lessons Learned
Successful Implementation - Prerequisites Barriers to Successful Implementations
 Organizations in the health care  Absence of integrative governance
community recognize that the and policy
successful implementation of CDPM
initiatives across providers may  Links all stakeholders groups.
require  Administrative and clinical
 Integrative governance accountabilities (Goulbourne 2007).
 Local leadership  Deployment of chronic disease care
 Cross-disease planning models in community settings suggest
 Strategy that organizations need help with:
 Multi-level partnerships  the strategic operationalization of
 Knowledge sharing integration dimensions ,
 Goal sharing
 the relational coordination of
 Information technology
process factors (Robinson et al 2007;
 Funding (Calnan et al. 2006, Robinson et al. Solberg et al 2006; Yach et al. 2004).
2007, Solberg et al. 2006, Wensing 2006).

34. Conceptual Model
The complex sustainable integrated care delivery system solutions we seek
require the implementation of „multisectoral, multidisciplinary and
multicomponent’ initiatives.
„Synergy, as it is manifested in the thoughts, relationships and actions within
the healthcare community, reflects the one aspect of collaboration that gives
partnerships that are able to achieve it a unique competitive advantage.‟
(Lasker et al. 2001)

35. Conceptual Model for CDPM Implementation
(Goulbourne 2007)
Shared goals,
a synchrony of efforts
and a synergy of effects.
Vertical
Integration
of
Structures
Horizontal Integration of Knowledge, Differentiation of Tasks and Services

36. Operational Model
A recent structured review of health care organizational interventions
revealed that benefits to clinical performance, patient outcomes and cost
reductions are empirically associated with transformations that include the
revision of professional roles (increased medical roles to nurses and a
widened scope of practice for pharmacists) and the use of computer systems
for knowledge management (Wensing et al. 2006).

37. Operational Model for CDPM – A Focus on Asthma
(Goulbourne 2007)

38. Shared Care
Shared care’ is the term that describes increasing the ability of…primary care
services, particularly GPs and pharmacists, to work more effectively…
www.cambsdaat.org/treatment/shared_care.html
The term shared care is used to describe the joint provision of care, not
necessarily in the same place or at the same time, by members of the primary
care team and of a specialist team. Shared care schemes generally focus on
diabetes, asthma and antenatal care, but several other conditions such as
inflammatory bowel disease and hypertension might benefit from components
of the shared care approach.
Priority Areas: First round Evaluation of Shared Schemes (Department of Health 2003)
http://www.dh.gov.uk/en/Policyandguidance/Researchanddevelopment/A-
Z/Primaryandsecondarycareinterface/DH_4015532

39. Governance, Networks and Synergy
Governance is commonly recognized as  Interior Health – Regional Health
being an important component to Authority, British Columbia Chronic
Disease Prevention Strategy
collaboration and functioning
partnerships.  Integrated Service Plan & Primary
Care Collaborative
The type of governance structure involved  PHC/CDM Director, Advisory Committee,
Change Management Team
in CDPM implementations is important.
 Integration of clinical and community health
Governance structures shape the nature and  Negotiated physician involvement and
composition of the partnerships, mode of participation via an alternate payment model
decision-making and impacts on the ways in  Link stakeholders and processes to provincial
initiatives
which partner perspectives, resources, skills  Translate provincial innovations to regional
and knowledge are combined. and local levels
Governance is said to have a “profound  Established Chronic Disease Health
Improvement Networks (6)
impact” of the level of synergy within the  Multiple disease orientation
partnership (Lasker, Weiss and Miller 2001, Touati et al.  Interdisciplinary team
2007).  Patient education and self-management
support
(Ockenden and Cheema 2004)

40. Collaborative Care:
Enhancing Clinical Service Network Link Overlap
Community based coalitions or sub-
networks may provide space where
organizations can develop levels of Acute Care
Integrative
synergy, exchange knowledge and Technology
work together to pursue shared goals.
Stronger cooperative ties are more
Patients Physicians
likely to develop among small clusters
of organizations than among multiple Shared
Community Primary
organizations in a broadly based Care Care Care
network (Provan and Sebatstian 1998). (EMR)
Pharmacists Nurses
Family Health Teams enhancing the
efficient use of health care resources.
Extra-Mural Program, New Brunswick
a provincial home health-care program Ambulatory
which is supported by a multidisciplinary Care
network of hospitals, health centres and
programs involved in health promotion,
education and the provision of
comprehensive health care services. (Goulbourne 2007)

41. New Roles for Pharmacists in Primary Care
and Community Care Settings
 Fraser Health Authority – Medication Management
New Roles and Collaborations Program, British Columbia Commenced in 2005
across Acute, Primary and  Pharmacist performs home visits to assess medication
Community Health Care regimens
Settings.  Target → Seniors recently discharged from hospitals
and clients high risk for drug related problems (6 or
Pharmacist deployed into new more medications)
settings where their drug expertise  Make recommendations to alleviate problems
is used to: (prescribing pre-measured blister-packed medications,
or eliminating unnecessary medications)
 Enhance patient medication  Pharmacists also perform academic detailing
practices, physician prescribing and
drug monitoring under treatment.  Grand River Hospital Corporation and New Vision Family
Health Team, Kitchener Ontario Commenced in 2006
 Enhance patient safety and  Pharmacist has a shared care role across acute (.5FTE)
optimal outcomes. Reduce the cost and primary care (.5FTE) sectors
of patient non-adherence
 Pharmacist provides drug information to
(readmissions), adverse drug events interdisciplinary clinical team
and after surgical intervention care.
 Collaborates in the development and deployment of
chronic disease prevention and management programs

42. We are doing better.
We will continue to do better.

43. References
 Goulbourne M. (2007). “Chronic Disease Prevention and Management: Examining regional
governance, network structures and outcomes.” (draft document)
 Kirby, M. (2002). “The Health of Canadians: The Federal Role Final Report. “ Ottawa: The
Standing Senate Committee on Social Affairs, Science and Technology.
 Lasker Roz D., Weiss Elisa S., et al. (2001). "Partnership Synergy: A Practical Framework for
Studying and Strengthening the Collaborative Advantage." The Millbank Quarterly 79(2): 179-
205.
 Ministry of Health and Long Term Care. (2007). “Ontario‟s Chronic Disease Prevention and
Management Framework : Work of a Steering Committee. Presentation by Meera Jain,
February 2007, Grimsby Ontario.
 Mohrman S.A. (2007). "Having Relevance and Impact: The Benefits of Integrating the
Perspectives of Design Science and Organizational Development." The Journal of Applied
Behavioral Science 43(1): 12-22.
 Ockenden, G. and Cheema G. (2004) “Addressing the Need for Improvement. The IH Chronic
Disease Management Plan 2004-2006”. Government of British Columbia.
 Provan Keith G. and Sebastian J.G. (1998). “Networks within Networks: Service Link Overlap,
Organizational Cliques, and Network Effectiveness." Academy of Management Journal 41(4):
453-463.

44. References Continued
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Prevention: Contributions of the Canadian Heart Health Initiative." Preventing Chronic Disease:
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 Solberg Leif I., Crain Lauren A., et al. (2006). "Care Quality and Implementation of the Chronic
Care Model: A Quantitative Study." Annals of Family Medicine 4(4): 310-316.
 Touati Nassera, Roberge Daniele, et al. (2007). "Governance, Health Policy Implementation and
the Added Value of Regionalization." healthcare Policy 2(3): 97-114.
 Wagner E.H., Austin B.T., et al. (2001). "Improving chronic illness care: translating evidence into
action." Health Affairs 20(6): 64-78.
 Wensing Michel, Wollersheim Hub, et al. (2006). "Organizational interventions to implement
improvements in patient care: a structured review of reviews." Implementation Science 1(2):
online journal.
 World Health Organization. (2005). WHO Global Forum on Chronic Disease Prevention and
Control: Final report of the meeting convened in Ottawa, Canada 3-6 November 2004. N. D.
a. M. H. Department of Chronic Diseases and Health Promotion, World Health Organization and
the Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, WHO.
 Yach Derek, Hawkes Corinna, et al. (2004). "The Global Burden of Chronic Diseases." Journal of
the American Medical Association 291: 2616-2622.