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SE CHC CDPM Network

South East Community Health Centres (CHCs) Chronic Disease Prevention & Management Network : An Integrated Approach to CDPM Carrie Salsbury, Program Director Gateway Community Health Centre on behalf of SE CHC CDMP Network. SE CHC CDPM Network. Country Roads CHC Gateway CHC Kingston CHC

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SE CHC CDPM Network

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  1. South East Community Health Centres (CHCs)Chronic Disease Prevention & Management Network:An Integrated Approach to CDPMCarrie Salsbury, Program DirectorGateway Community Health Centreon behalf of SE CHC CDMP Network

  2. SE CHC CDPM Network • Country Roads CHC • Gateway CHC • Kingston CHC • Merrickville CHC • Susan Turnbull • Carrie Salsbury • Mike Bell (Chair) • Ray Elgersma

  3. growing prevalence and burden of chronic illness in our population CDPM that is based on quality improvement principles, teams and clinical practice guidelines is supported Strategies that demonstrate improved care and health outcomes for population with CD Acknowledgement of CHC success with team & guidelines-based care Ministry Messages

  4. Data confirms population is aging, chronic disease is increasing Significant health care capacity and cost/sustainability concern LHIN wants change that promotes improved access to integrated approaches, is team-based, promotes measureable health outcomes & contains system costs Priority areas include primary care systems, ehealth tools and connectivity, regional program continuums Focus from Ministry is diabetes as first round LHIN Messages

  5. To Establish: Collaborative partnerships among CHCs with a focus on Increasing Service Quality and Evidence Based Practice Common CDPM indicator framework Collaborative Partnership CDSMP – Living Well with Chronic Conditions Stroke Prevention- improve processes to recognize and address common risk factors in primary health care. Increase uptake of HP practice by PHC providers SE CHCs CDPM Network Purpose 2008-10

  6. Reduced burden of chronic disease for clients & the health care system Reduced complications, preventable ER & specialist visits Improved quality of life for clients with chronic conditions Long-Term Outcomes

  7. Network Areas of Focus • Self Management • Stroke Prevention Strategy • Indicator Development

  8. 1. SELF MANAGEMENTLiving Well…With Chronic Conditions A SE CHCs Chronic Disease Self-Management Collaborative Program

  9. Increase number of individuals with chronic illness receiving training in self management skills Increase number of individuals trained to deliver the Stanford SM Program Establish structure and processes to coordinate and maximize existing resources Establish regional plan for CDSMP OBJECTIVES

  10. Self Management Network includes 16 organizations (CHC’s FHT’s & CSS 10 Master Trainers 29 Staff Leaders 17 Lay Leaders 250 participants (CHC only) 12 sessions completed for 2009/10 (CHC only) Creation of common data base for group evaluation CDPM Achievements

  11. Continue to educate, develop common marketing strategies to recruit participants Strengthen relationships with non CHC partners and create support network for Self Management leaders Develop & maintain a regional training schedule Investigate the potential for a regional license Investigate development of a regional website Evaluation – beyond self efficacy to include: healthy behaviour, health status and health utilization data Where are we going ….

  12. Project Goals: To increase awareness of risk factors of stroke To increase the uptake of health promotion concepts by primary health care teams To improve outcomes / reduce risk for clients by identifying risk, providing education & referral to health promotion and community prevention resources 2. STROKE PREVENTION

  13. Review and analyze project documents – proposal, progress reports, group feedback forms Review and analyze evaluation tools and indicators Semi-structured interviews with health promotion champions, providers and clients (21 total) Pre and post provider surveys Pre and post client surveys Project intervention chart summaries Evaluation Methods

  14. Primary Prevention Common risk assessment screening tool for stroke Provider survey Motivational interviewing training for over 90 practitioners Client education tool kit Developed clinical pathways for primary and secondary prevention Achievements

  15. What did the project achieve? • Uniqueness means distinctive strengths and challenges across sites • No easy roll up of results and numbers • Limitations of evaluation tools • Highlight common results across sites in three areas: for providers, for clients, for CHCs

  16. % of Men over age 40 with a BP measurement in a 24 month period

  17. % of Men over age 40 with a lipid profile in a 24 month period

  18. % of Woman over age 50 with a lipid profile in a 24 mth period

  19. Clients over age 18 with obesity screening in 24 month period

  20. Results for providers • Increased awareness of community resources

  21. Results for providers • Increased referrals to CHC programs or community resources

  22. Results for CHCs The project intended to touch: • Interdisciplinary primary health care teams- increased use of health promotion concepts • Clients– better outcomes and reduced risk • CHCs/Organizations – new and more effective ways (systems, practices, norms) to do health promotion that will continue after the project

  23. Results for CHCs • Mixed impact on ongoing health promotion practices from high to low on a continuum Highest ongoing impact in CHCs who began with a plan to integrate project activities into ongoing work and who used both individual and group approaches Lowest ongoing impact in CHCs who used a group approach only and did not effectively link individual clients with primary care providers

  24. 3. INDICATOR DEVELOPMENT Varying approaches to evidence based practices in an interdisciplinary model that involves: individual and group sessions community capacity building broad based prevention strategies

  25. Plan DO act Study Quality Improvement in Primary Health Care Service Delivery • PDSA Cycle: model assists primary health care teams to: • think about a problem for change • design and test smaller focused changes • adopt changes that work into practice on a larger scale • move on to the next problem • Helps teams to think and work together on problem solving, setting goals, managing emotions/interactions

  26. Healthy Public Policy • Anti-smoking legislation • Income security, affordable housing, employment protection Health System (Health Care Organizations) • Supportive Environments • Affordable housing • Food security • Affordable recreation • Personal Skills & • Self-Management • Support • Information & education with physician • Information & education with RN/NP/RD in clinic • Diabetes Education • Stanford CD SMP • Delivery system Design • Interdisciplinary teams • Diabetes clinic • Planned appts & quarterly testing/goal setting • Diabetes education program • Referrals to DEP, CDSMP, exercise programs, with monitoring & follow-up • Provider Decision • Support • Current CPG formally embedded in daily practice • Key indicators reports (CDA CPG) • Alerts & reminders in Purkinje development • CPOE, ECR, paper when necessary • Information Systems • Patient registry • Recall/reminders • Info access to all team members • Alerts & reminders in Purkinje • ECR, eLabs, paper when necessary Community • Community Action • Exercise programs • Food security/good food box • REACH • Lay Lead CD SMP SE CHCs Common CDPM Framework – Diabetes Continuum Productive interactions and relationships Activated communities & prepared, proactive community partners Informed, activated, Individuals & families Prepared, proactive, practice teams Improved clinical, functional and population outcomes Adapted from MOHLTC Ontario’s CDPM Framework, Nov. 2006 LHIN think Tank CDPM

  27. SEISUG – South East Information User Group support achievements of SE CDPM Network Developed a standardized evaluation tool to measure outcomes of current CDPM initiatives queries using the Hummingbird BI application tool extract results directly from the Purkinje database

  28. % of primary care clients with the following chronic diseases

  29. % of active diabetes clients Numerator: # of active primary care clients with diabetes between age range Denominator: Total # of primary care clients at CHC Calculation: = # of diabetic clients / Total # of primary care clients*100 Inclusion Criteria: diabetic clients between age 18 and 75 with an active status and are registered to a physician or a nurse practitioner. Exclusion Criteria: Does not include clients registered to a personal development group or a community initiative. SE CHC Average: 6.5%

  30. % of DM clients with HbA1C result less than 7 Numerator: # of active diabetic clients with an HbA1C test less than or equal to 7 Denominator: Total diabetic clients who have had an Hb1C test in past 6 months Calculation: = active diabetic clients with HbA1C test in past 6 months and a result <=7*100 Total active diabetic clients who have had a HbA1C test Inclusion Criteria: between 18 and 75 with an active status and are registered to a physician or a nurse practitioner. The result code description contains HbA1C and the result must equal or be less than 7. Exclusion Criteria: does not include clients solely registered to a personal development group or CI.

  31. % of DM clients with a self-management goal in past year Numerator: # of diabetic clients with a self-management goal Denominator:# of active primary care clients with diabetes between 18 and 75 Calculation: = # of diabetic clients with a self management goal *100 total # of diabetic clients Inclusion Criteria: between 18 and 75 with an active status and are registered to a physician or a nurse practitioner. Exclusion Criteria: does not include group clients. Limitations/ Data Quality Issues: Self-management is a recent concept integrated into CHC's. DMC's have struggled with where to place this information in the client chart to ensure that results can be reported, which has taken some time.

  32. % of DM clients with LDL < 2.0 Numerator: # of active diabetic clients with LDL less than 2 Denominator: Total active primary care diabetes clients between age range with LDL result Calculation: = # of DM clients with LDL result <2 * 100 Total active diabetic clients with a LDL test completed within timeframe Inclusion Criteria: diabetes clients between 18 and 75 with an active status and are registered to a physician or a nurse practitioner with at least once LDL result. Exclusion Criteria: does not include clients solely registered to a personal development group or CI.

  33. Quality Improvement Common indicators developed for diabetes and hypertension Developing common data definitions, data queries to extract information from EMR to support analysis and quality improvement Developing capacity to link impact of SDOH on health outcomes Achievements

  34. Common vision and purpose Common LHIN wide approach to and implementation of Best Practice Guidelines Regional indicator development and evaluation Embedding Self Management into primary care practice Embedding health promotion into primary care practice CDPM NETWORK ACHEIVEMENTS

  35. Questions and Discussion!

  36. Carrie Salsbury – Member SE CHC CDPM Network Gateway CHC (613) 478-1211 Ext 246 csalsbury@gatewaychc.org Laura Cassidy – Chair SEISUG Gateway CHC (613) 478 -1211 Ext 298 lcassidy@gatewaychc.org Contact Us

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