GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORK

Transcription

1 GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORK IMPLEMENTATION TOOL KIT Bumstead, L., Goetz-Perry, C., Miller, L., Solomon, M. (2008) 1

2 WHERE DID THE CDPM FRAMEWORK COME FROM? Wagner (1999) Barr et al (2002) Ontario Ministry of Health and Long term Care The health care system transformation agenda 2

3 CDPM Framework - Purpose To provide a common policy framework to guide efforts toward effective prevention and management of chronic diseases To guide Ministry transformation initiatives such as: Local Health Integration Networks Primary Health Care Renewal, Family Health Teams Public Health Renewal - health promotion and prevention initiatives e-health strategy, HHR strategy Specific chronic disease strategies To engage ministry stakeholders in a systematic approach to addressing chronic disease 3

4 CDPM Framework: Purpose Not just a model: changes the paradigm for care A way for conceptualizing care A framework for organizing or re- organizing care Applicable to any system, organization or program 4

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6 What Makes People Healthy / Unhealthy? Estimated Impact of Determinants of Health on the Health Status of the Population Biology and Genetic Endowment 15% Health Care System 25% Physical Environment 10% Social and Economic Environment 50% 6

7 FROM Illness orientation The Transformation TO Wellness orientation prevention not a priority a solo provider approach Provider, disease centred reactive and episodic care limited role for individuals in self management prevention at all points of continuum an integrated, interdisciplinary care team approach patient centred proactive, complex, continuing care individuals empowered for self- management and part of care team A System Involving Health Care Organizations Individuals and Families Communities 7

8 Why does the CDPM system have that capacity? Focuses on populations Focuses on longitudinal care (creates a system of prevention and care) Supports coordination of prevention and care along a health continuum Recognizes individuals and communities as partners Offers early access to prevention and support as well as treatment Offers multi-disciplinary, multi-sectoral strategies 8

9 WHAT IS THE KIT? Written and electronic resources that help groups understand the framework, and develop practical applications for it Step-by by-step support to apply the framework to your existing programs, or build new ones A way of establishing a common perspective and language between partners when undertaking new strategies related to chronic disease prevention and management 9

10 HOW DO WE USE THE KIT? Identify the current or potential program, project or partnership initiative requiring development/reassessment/redesign Establish a core stakeholder work group Use the resources, references, and steps outlined in the tool kit as process supports for developmental activities 10

11 OVERVIEW OF FRAMEWORK APPLICATION: THE WORKFLOW 11

12 CDPM Framework Workflow Understanding the Framework Step 1 Review the Ontario Chronic Disease Prevention and Management Framework diagram. Step 2 Review the Element Definitions in CDPM Step 3 Review the Logic Models Applying the Framework Step 4 Complete Program Feasibility Checklist Step 5 Complete the Logic Model for Program Planning Step 6 Complete the Initiating a Health Program Checklist Step 7 Revise Program (Logic Model) Plan as required 12

13 Step I: REVIEW THE OCDPM FRAMEWORK DIAGRAM 13

14 Supportive Environments Ontario s CDPM Framework Healthy Public Policy INDIVIDUALS AND FAMILIES Personal Skills & Self- Management Support HEALTH CARE ORGANIZATIONS Community Action Delivery System Design Provider Decision Support Information Systems Productive interactions and relationships Activated communities & prepared, proactive community partners Informed, activated individuals & families Prepared, proactive practice teams Improved clinical, functional and population health outcomes 14

15 STEP 2: REVIEW THE ELEMENT DEFINITIONS IN THE OCDPM DIAGRAM 15

16 Individuals and Families The centre of the CDPM framework Direct involvement and self management of health and chronic diseases is key Team members in prevention and care Informed, person-centred choices for living 16

17 Health Care Organizations - make systematic efforts to improve prevention and management of chronic disease: strong leadership (e.g., CDPM champions) alignment of resources, incentives (e.g. Admin support, IT support for providers, etc.) accountability for results (e.g., set goals, measure effectiveness in improving outcomes for clients, population and system ) 17

18 Personal Skills & Self-Management Support - empower individuals to build skills for healthy living and coping with disease: emphasizing the individual s s and families central role in their health, and as a member of the care team engaging them in shared decision-making, goal-setting and care planning providing access to education programs & health information (e.g. asthma education programs, consumer information) behaviour modification programs (e.g. smoking cessation) counselling and support services (e.g. self-management support groups) integration of community resources (e.g. referral to community physical activity programs) follow-up (e.g. reminders, self-monitoring assistance) 18

19 Delivery System Design - focus on prevention and, improve access, continuity of care and flow through the system: interdisciplinary teams (e.g., FHTs with defined roles & responsibilities) integrated health promotion and disease prevention (e.g., nutrition and physical activity counselling) planned interactions, active follow-up (e.g., care paths, case management) adjustments, innovations in practice (e.g., group office visits, central appointment booking service) outreach and population needs-based care (e.g., Latin American Diabetes) 19

20 Provider Decision Support - integrate evidence-based guidelines into daily practice: easily accessible clinical practice guidelines (e.g. web-based, based, interactive) tools (e.g. disease/risk assessment, management flow sheets, drug interaction software) provider alerts and reminders (e.g. reminders for tests, examinations) access to specialist expertise (e.g. team social worker; cardiologist ogist at tertiary care centre) provider education (e.g. working in interdisciplinary teams, collaboratives) measurement, routine reporting/feedback, evaluation (e.g. continuous quality improvement loop for target blood glucose levels els in client population with diabetes) 20

21 Information Systems are essential for enhancing information for providers to provide quality care; for clients to support them in managing their disease on a day to day basis; and for integrating services across health system: electronic health records (e.g. personal health information, test results, prevention and treatment plans) client registries to identify and provide patient subpopulations with proactive care, monitoring, and follow-up (e.g. tracking systems, automated reminders) links (e.g. between team members, care centres) information for clients (e.g. health care advice, access to records, community resources) population health data (e.g. demographic, health status, risks) 21

22 Healthy Public Policy - develop and implement policies to improve individual and population health and address inequities: legislation, regulations (e.g. smoking by-laws) fiscal, taxation measures (e.g. lowering duty on imported fruit) guidelines (e.g. Health Canada food guidelines, screening) organizational change (e.g. flex hours, day care in the workplace) 22

23 Supportive Environments - remove barriers to healthy living and promote safe, enjoyable living and working conditions: physical environments (e.g. safe air, clean water, accessible transportation, affordable housing, walking trails, bicycle lanes) social and community environments (e.g. daily physical activity in schools, seniors programs in community centres, on-site health promotion programs in the workplace) 23

24 Community Action - encourage communities to increase control over issues affecting health: collaboration between the health care sector and community organizations (e.g. Latin American Diabetes Program, London ON) effective public participation and intersectoral collaboration (e.g.( community members, private sector and schools providing breakfast nutrition/physical activity programs) 24

25 STEP 3:REVIEW THE LOGIC MODELS Mission A systems approach to provide integrated chronic disease prevention and management services Inputs Policy, Legislation/Regulations, Guidelines, Fiscal and Human Resources, Information Systems Components Community Capacity and Integration Individual and Family Capacity and Integration Health Care Organization (HCO) and Provider Capacity and Integration Outputs Communities collaborating with HCOs to identify and prioritize issues affecting the health of the population. Communities championing activities for healthy public policy, and supportive environments. Community collaboration with HCOs to develop, link and coordinate services and information for individuals and families. Community information and programs integrated with health care services. Education, counselling, behaviour modification programs, and information for individuals and families to build skills for healthy living and coping with disease. Care teams with individuals and families at the centre, and engaged in decision making and care planning. Self-management information and resources accessible and tailored to meet the needs of individuals and families. Community programs and resources integrated into care. Health promotion, primary, secondary, and tertiary prevention incorporated into care. Visible leadership, aligned incentives, policies, resources, measurement, and accountability for CDPM system changes. Interdisciplinary team practices, with links to specialists, where health care providers collaboratively provide patient-centred care in a seamless and coordinated manner. Integrated electronic information systems with comprehensive, accurate information for providers and individuals to share information & make the best decisions. Evidence-based tools for prevention, assessment and management incorporating planned interactions, and prompts for follow-up. Short-term outcomes Increased community collaboration with HCOs to identify and prioritize issues affecting health. Increased community action for healthy public policy, supportive environments to meet the needs of their population. Increased awareness, linkages and referral to community programs, information, and resources. Individuals and families have increased skills and knowledge for healthy behaviours. Individuals, families and providers have improved understanding of their roles as partners on care teams, and consumers are involved in care planning. More individuals and families have increased knowledge of their disease processes and role as daily self-manager. Increased knowledge and skills of consumers in selfmanagement. More individuals and families are aware of and linked to community programs and resources. Providers have increased knowledge, skills and tools to incorporate prevention into their practices. More HCOs promote system change and provide incentives, align policies, resources, measurement, and accountability. Increased number of interdisciplinary teams, with links to specialists working collaboratively and providing coordinated, patient-centred care. More providers using electronic information systems and sharing information among team members, their clients, other health providers and settings. More providers using evidence-based tools, and quality improvement approaches for prevention, assessment and management. Intermediate outcomes Improved healthy public policies and supportive environments. More community information and programs integrated with health care services. More people exhibiting healthy behaviours Individuals and families at the centre of the care team, actively engaged in decision-making, and daily managers of their wellness. More individuals and families gaining benefits through involvement in self-management Increased participation in community programs and resources Increased overall satisfaction of individuals and families with the responsiveness of the health care system to meet their needs Health promotion and prevention integrated across continuum of care. Health care coordinated across the continuum of care, providers and settings. The appropriate type and number of health care providers working in collaboration to meet the needs of the individual and family. Care is evidence based and meets the diverse needs of consumers. Care is proactive, and provides for complex and continuing care, with follow-up and ease of navigation. Integrated information systems with consumer, decision support and community information. Long-term outcomes Activated communities and prepared, proactive partners Informed, engaged individuals and families Prepared, proactive practice teams Vision An integrated, coordinated system for the prevention and management of chronic diseases that is proactive, individual and family-centred, and that provides access to quality care by the right provider at the right time in the right place, resulting in improved clinical, functional and population health outcomes 25

26 Mission A systems approach to provide integrated chronic disease prevention and management services Roles and Responsibilities Components Health Promotion Primary Prevention Community Capacity and Integration Roles Responsibility Individual and Family Capacity Roles Responsibility Health Care Organization Roles Responsibility Secondary Prevention Tertiary Prevention 26

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28 STEPS 4-7: 4 BUILDING YOUR PROGRAM 28

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30 Developing Logic Models 30

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33 Program Name Problem Statement: Program Goal (s): Logic Model Activities What happens in our organization? Resources What resources do we have to work with? Outputs What are the tangible products of our activities? Short-term Outcomes What changes do we expect to occur within the short term? Intermediate Outcomes What changes do we want to see occur after that? Long-term Outcomes What changes do we hope to see over time? Rationale (s): The explanation of a set of beliefs, based on a body of knowledge, about how change occurs in your field and with your specific clients (or audience). Assumptions: Facts or conditions you assume to be true. External Factors: 33

34 A VALUABLE REFERENCE FOR PROGRAM PLANNING USING THE LOGIC MODEL APPROACH: Innovation Network, Inc. (2005) Logic model workbook 34

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36 GB-CDPM FRAMEWORK TOOLKIT PLANNING GROUP Lynda Bumstead Grey Bruce Health Unit Nancy Dool-Kontio Southwest Community Care Access Centre Cathy Goetz-Perry Grey Bruce Victorian Order of Nurses Carolyn Grace Owen Sound Family health Team Jessica Meleskie Grey Bruce Health Network Lisa Miller Grey Bruce Diabetes Program Susan Pouget Closing The Gap Health Care Group Grey Bruce Mary Solomon Grey Bruce District Stroke Centre Michelle Walter Brockton and Area Family Health Team 36