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Barrie Community Health Centre Barrie, Ontario, Canada Carla Palmer B.Sc, M.Sc.

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Barrie Community Health Centre Barrie, Ontario, Canada Carla Palmer B.Sc, M.Sc.

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    1. Barrie Community Health Centre Barrie, Ontario, Canada Carla Palmer B.Sc, M.Sc. Diabetes: A preventable epidemic An integrated prevention and care pathway using Strategy Mapping/Balanced Scorecard Methodology

    4. CHCs in Ontario

    6. Diabetes Morbidity

    7. Providers functioning like islands Providers working to full capacity, as individuals, not as a team No mechanisms to ensure clients were accessing the right care in the Centre or in the community No linkage between prevention and care

    8. Integration and Accountability ‘Imagine a primary care centre that has organised its professionals in a network, but where communication and exchange of information between professionals is poor. Though this centre may appear integrated from the provider perspective, for the user, navigating the system has not been made any easier. From his perspective, care is still fragmented.’ (Wait, European Social Network Conference, Edinburgh 2005) Cited in Integrated Care: A Guide for Policy-makers (James Lloyd and Suzanne Wait)

    9. BCHC Vision Statement Barrie Community Health Centre is recognized as an innovative, responsive and relevant health care partner along the health care continuum advancing the health of individuals and the community through integrated prevention and care pathways.

    10. BCHC Key Strategic Result Advance and balance prevention and primary care for the individual and the community to improve health outcomes, reduce avoidable use of healthcare services, and build on our communities’ strengths

    11. Enabling the Goal for Integrating Prevention and Care Measurable description of the future Consensus about targets Approved strategic framework Highest priority for focus Staff supported to implement and measure their strategy for integration Bengt Ahgren and Runo Axelsson, Evaluating Integrated Health Care: A system of measurement, Internation Journal of Integration Care, 31 August 2005

    12. Enabling the Goal for Integrating Prevention and Care Structure follows strategy Guus Schrijvers, Editorial, International Journal of Integrated Care, November 2005

    16. Diabetes: A Preventable Epidemic

    17. Diabetes: A Preventable Epidemic

    18. Diabetes: A Preventable Epidemic

    19. Diabetes: A Preventable Epidemic

    20. Diabetes: A Preventable Epidemic

    21. Diabetes: A Preventable Epidemic

    22. Diabetes: A Preventable Epidemic

    23. Results: Financial Refocusing continuing education budget Re-allocating staff from relocating 5 physiotherapy-led exercise classes to resources within the community

    24. Results: Learning and Growth Selection of and training in use of evidence-based interdisciplinary best practice tool Two staff and one volunteer have received training in the Stanford model of Chronic Disease Self Management at Stanford University in California

    25. Results: Internal Processes it has been audited that all team staff members are using the best practice tool staff sit on new organization teams related to the integrated prevention and care pathways of which diabetes is one the Centre’s Health Service Manager sits as Chairman on the inter-agency Diabetes Collaborative

    26. Results: Client Outcomes Increase healthy nutrition and activity levels improvement of eating habits and activity levels reported by 50% of BCHC playgroup participants & 50% of clinical clients breastfeeding initiated by 90% of new mothers who use BCHC clinical services or Teen Parent and Young Parent programs 60% will breastfeed exclusively for 6 months Improve clinical status 5 – 7% reduction in weight within 1 year by 50% of BCHC clinical clients with a high BMI (= 27) or an ‘at risk’ waist circumference improvement in diabetic clinical status by 50% of BCHC clinical clients Increase self-management skills and strategies passing score on a Diabetes Self-care Assessment & an acceptable score on the Diabetes Quality of Life scale achieved by 70% of BCHC clients attending the BCHC Diabetes Management Centre program Barrie Community Health CentreBarrie Community Health Centre

    27. Client Story L.G is a 67 yr old retired man referred by a physician outside the centre to the BCHC Diabetes Management Centre One-on-one consultation with nurse and dietitian Diabetes education program re nutrition, fitness and self management re blood glucose levels Regular monitoring of A1c levels by his physician 3 mo results: 28 pounds weight loss, 3% decrease in the A1c level

    28. Conclusion Enablers of Success we believe we have achieved through Strategy Mapping and Balanced Scorecard Methodology Structure follows strategy Consensus about integration targets Targets in a strategic framework Evaluation data guide managers and providers Change management priority, linked by accountabilities, with the achievement of one objective driving the other Ongoing Challenges: Information system Interagency collaboration – process to define new roles, and bridge between organizational cultures

    29. References Integrated Prevention and Care Lloyd, James and Wait, Suzanne, Integrated Care: A Guide for Policymakers, Report from the European Social Network Conference, Edinburgh, 2005 Ahgren, Bengt and Axelsson, Runo, Evaluating Integrated Health Care: a model for measurement, International Journal of Integrated Care, 31 August 2005 Schrijvers, Guus, Prevention and Cure should be integrated (editorial). International Journal of Integrated Care, 2 November 2005 Chronic Disease Prevention and Care Haydon, Emma, et al, Chronic Disease in Ontario and Canada: Determinants, Risk Factors and Prevention Priorities, Prepared for the Ontario Chronic Disease Prevention Alliance and the Ontario Public Health Association, March 2006 WHO, Innovative Care for Chronic Conditions: Building Blocks for Action, 2002 Hurtubise, Michelle and Harvey, Betty, Presentation: Diabetes Care at the London InterCommunity Health Centre (Ontario), May 2006 Strategy Mapping and Balanced Scorecard Kaplan, Robert S. and Norton, David P., Having Trouble with Your Strategy? Then Map It, Harvard Business Review, September-October 2000 (www.hbr.org Product 5165) Kaplan, Robert S. and Norton, David P., Strategy Maps, Harvard Business School Publishing Corporation, 2004 Niven, Paul R., Balanced Scorecard Step-by-Step for Government and Nonprofit Agencies, John Wiley and Sons, Inc, 2003

    31. Thank you Acknowledgements: Barrie Community Health Centre Board of Directors for their leadership, Christine Colcy (Health Services Manager) for her operational expertise to bring life to the Balanced Scorecard and BCHC staff for their perseverance to implement it, and the Southwest Ontario CHC Executive Directors Group for their support of my work and the expense of registration for this conference.

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