Chronic Disease Management & Prevention System Level Logic Model

Chronic Disease Management & Prevention System Level Logic Model Prepared by : Planning Subcommittee Members: Dr. Louis Balogh, Regional Vice President, Southlake Regional Health Centre Ms. Kathy Condie, Director, Central Community Care Access Centre Mr. Malcolm Moffat, President & CEO St. John s Rehabilitation Hospital Ms. Carla Palmer, Director, York Central Hospital Consultants: Dr. Brian Rush, VIRGO Planning and Evaluation Consulting Dr. Michael Rachlis, Health Policy Analysis Central LHIN Staff Ms. Anne Lessio, Senior Planner (Author) Ms. Emily Wong, Administrative Assistant March 31, 2009 CDMP System Level Logic Model March 31, 2009 0

Table of Contents Executive Summary... 2 1. Project Purpose... 4 2. Introduction: Chronic Disease in Central LHIN... 5 3. Contextual Factors... 7 3.1 Internal to Central LHIN... 7 3.1.1 Mandate of Central LHIN... 7 3.1.2 Integrated Health Service Plan... 8 3.1.2 Outcome Map... 8 3.2 External contextual factors... 9 3.2.1 Ministry of Health Chronic Disease Prevention and Management Framework... 9 4. The Planning Process... 10 5. The Plan... 10 5.1 Rationale for the Logic model... 10 5.2 Description of Logic Model... 11 5.3 Description of Activities within the CDMP System Level Logic Model... 12 5.3.1 Population Health... 13 5.3.1 Population Health... 14 5.3.2 Health Care Organizations... 15 5.3.2 Health Care Organizations... 16 5.3.3 Delivery System Design... 17 5.3.4 Self Management... 24 5.3.5 Provider Decision Support... 25 5.3.6 Information Systems... 26 6.0 Prioritizing Activities for Action... 27 7.0 Summary... 28 Appendices... 29 CDMP System Level Logic Model March 31, 2009 1

Executive Summary Chronic diseases are long-term conditions that develop slowly over time, often progressing in severity and are typically controlled but rarely cured. Many recent documents have attempted to quantify the financial burden of chronic diseases including WHO s estimate of Canada s direct and indirect costs nearing a massive $89 billion per year. Central LHIN s calculated share of this is a colossal $4.1 billion annually. Currently in Central LHIN, chronic diseases account for 25% of inpatient hospital cases, 10% of emergency department visits and 20% of family physician visits 1. Forty-two percent (42%) of Central LHIN residents aged 65+ have two or more chronic diseases 2. Given the magnitude of the issue and the burden to the health system and to patients and their families, a system-level plan for CDMP that is coordinated, comprehensive and sustainable was created. The current health system in Ontario is designed for acute episodic illness rather than long-term chronic disease. The system is based upon clients contacting the system and passively receiving their health care and treatment by the health professionals. A more responsive system consists of proactive, planned, integrated care where patients are active participants in their own treatment and care. Effective management of chronic disease includes prevention measures to delay onset of the disease and slow progression towards complications. The Ministry of Health and Long-Term Care (MOHLTC) developed a policy framework to help guide the redesign of the health care system to improve chronic disease prevention and management. Ontario adapted the Expanded Chronic Care Model (CCM) by expanding the Population Health component to include: Healthy Public Policy; Supportive Environments; and Community Action; and maintained the five components constituting the original Wagner Chronic Care Model consisting of: Health Care Organization; Personal Skills and Self-Management; Delivery System Design; Provider Decision Support; and Information Systems. A recent meta-analysis 3 of 112 studies about the CCM assessed whether any of the elements of the model are essential for improving outcomes. The authors found that: Changes to the delivery system design significantly improved processes and patient outcomes Self management support significantly improved processes and patient outcomes; Decision support improved care processes but not patient outcomes There were no significant benefits from clinical information systems Given the evidence available, the MOHLTC framework was used as the foundation for the Central LHIN CDMP System Level plan and a separate plan for the Delivery System Design was created. To reach their full potential in Central LHIN, both the System Level CDMP and Delivery System Design Plans must be communicated effectively where all Health Service Providers (HSPs) easily understand how their unique contributions advance the overall health system redesign process. Logic models are a widely accepted tool within the health sector in Ontario as they are particularly useful for communicating the essential nature and purposes of activities associated with a particular plan. A logic model breaks the plan down into component parts and then specifies the logical and sequential links between the activities or processes to be implemented 1 Central LHIN Health Service Needs Assessment and Gap Analysis, KPMG, Toronto, Nov. 2008 2 Chronic Conditions in the Central LHIN, Health System Intelligence Project, Ministry of Health, Oct. 2007 3 Improving Care for People with Long-Term Conditions: A Review of UK and International Frameworks, National Health Service, 2007 CDMP System Level Logic Model March 31, 2009 2

and the type of longer-term outcomes to be achieved as a result of implementing these activities. The logic model for the CDMP System Level plan is on page 13 of this document and the Delivery System Design logic model is on page 17. The process of developing a logic model is also widely seen as helpful for clarifying objectives and consensus building, which are especially helpful for implementation. An iterative approach engaging members of the CDMP Advisory Network, consultants and staff was used to create the logic models Given the mandate of the LHIN as a health system manager, the CDMP plan is designed to support reorientation and strengthening of the health care system, enabling HSPs to respond more effectively and equitably to the health-care needs of people with chronic diseases, in line with MOHLTC and Central LHIN priorities. The two logic models, CDMP System Level Plan and Deliver System Design, clearly illustrate the linkages between continuum of service, strategic initiatives and impact on Emergency Department and Alternate Level of Care. The two logic models comprise a set of actions which, when performed collectively by all HSPs within Central LHIN will tackle the growing burden imposed by chronic disease. The logic models serve to illustrate the interdependencies and integration opportunities along the entire continuum of service for chronic disease prevention and management. The logic models plainly identify activities to improve patient transitions between acute, post-acute and community care to ensure continuity of care. The two logic models clearly illustrate the interdependencies and necessary partnerships between the various Health Service Providers when redesigning the delivery system and incorporating new supports such as Patient Self Management. The graphic representation provided by the logic models permits sequencing initiatives to best leverage the gains made by changing the delivery system. Using wide-ranging criteria, the CDMP Advisory Network selected the first set of priorities for action from the two logic models as shown below. Priorities for Action Self management supports and programs for high risk patient groups (i.e. the patients using a high amount of health care services) Delivery system design changes including: o Transitions and care algorithms between Acute/Post Acute/ Community care o Primary care services through different models e.g. Community Health Centres or Nurse Practitioner led teams o Screening programs Primary and Secondary Prevention programs for chronic disease Supporting healthy public policy initiatives Building capacity for CDMP in health care organizations using draft CDMP Accreditation Canada standards CDMP System Level Logic Model March 31, 2009 3

1. Project Purpose Chronic diseases are long-term conditions which develop slowly over time, often progressing in severity and are typically controlled but rarely cured. They include conditions such as cardiovascular disease, cancer, diabetes, and arthritis. Chronic diseases are the leading causes of death and disability worldwide and yet many chronic conditions can be prevented or have their onset delayed by modifying some high risk lifestyle risk factors including: smoking, physical inactivity, unhealthy eating and alcohol abuse. Many recent documents have reported the financial burden of chronic diseases. The highest of those estimates, from the WHO, identified the direct and indirect cost of chronic diseases in Canada nearing a massive $89 billion annually. Central LHIN s calculated share of this is a colossal $4.1 billion annually. Another estimate by Health Canada places the combined direct and indirect costs of cardiovascular disease, diabetes and mental health at $64 billion annually in Canada with $3.2 billion being contributed by Central LHIN based on population. In short, chronic disease accounts for a disproportionate cost on the health care system. People, as well as the health care system, are significantly impacted by chronic disease. Currently in Central LHIN, 31% of residents had at least one chronic disease while 42% of residents aged 65+ had two or more. Approximately 46% of the population aged 12+ were physically inactive and 44% of those aged 18+ were either overweight or obese 4 Because of magnitude of the issue and the cost to the health care system, a coordinated, comprehensive system-level plan for Central LHIN was deemed imperative. Overall Project Goal: Create a system-level plan for chronic disease management and prevention that is coordinated, comprehensive and sustainable and addresses system issues, incorporates prevention and embeds the Central LHIN and Ministry of Health priorities. The project commenced in January 2009 and finished in March 31, 2009. 4 Chronic Conditions in the Central LHIN, Health System Intelligence Project, Ministry of Health, Oct. 2007 CDMP System Level Logic Model March 31, 2009 4

2. Introduction: Chronic Disease in Central LHIN The population in the LHIN is generally healthier, younger and wealthier when compared to the Ontario average. Currently the prevalence of many chronic conditions is below the provincial average as shown in Figure 1. However, it is important to note that within the Central LHIN the population is not homogeneous and there are some sub-lhin planning areas that have a higher-than-ontario average for certain conditions e.g. diabetes as illustrated in Figure 2. Figure 1: Prevalence of Chronic Conditions in Central LHIN and Ontario, 2005 5 Arthritis Hypertension Asthma Heart Diabetes Depression CODP Cancer Stroke Disease Central 14.2 12.4 6.8 4.3 4.0 3.1 3.1 1.5 0.9 Ontario 17.2 15.4 8.0 4.8 4.8 4.8 4.1 1.5 1.1 Figure 2: From ICES online In Tool application (www.ices.on.ca) 5 Central LHIN Health Service Needs Assessment and Gap Analysis, KPMG, Toronto, Nov. 2008; CDMP section page 2 CDMP System Level Logic Model March 31, 2009 5

A wide range of risk factors influences the onset and prognosis of chronic disease including age, socioeconomic factors, social determinants of health and behavioral lifestyle factors. Age is a major risk factor. Not only do people over the age of 65 years have a higher prevalence of chronic disease but they are more likely to have multiple chronic conditions. With the population in the Central LHIN aging faster than the Ontario average, the prevalence rates for chronic disease are expected to rise and surpass the Ontario average. Behavioral risk factors are those related to lifestyle and are modifiable. Changes in the prevalence of the most common risk factors smoking, inactivity, unhealthy eating and misuse of alcohol lead to substantial reductions of chronic disease. For example, the amount of chronic disease attributable to physical inactivity is considerable. In Central LHIN, the 46% of the population considered physically inactive accounts for 81,000 (16%) of type 2 diabetes cases and 116,400 (24%) ischemic heart disease cases. The initial cost effectiveness studies on preventing diabetes show a reduction of $877,000/year for every 1% increase in the number of Ontarians who are physically active 6. Central LHIN, home to 12.9% of the Ontario population, would experience a reduction of $114,010 for every 1% increase in the number of people who become physically active or $5,244,460 if all the currently inactive became physically active. As well as lifestyle choices, there is compelling evidence that chronic diseases are related to the social determinants of health. Social determinants of health (SDOH) are the economic and social conditions that influence the health of individuals, communities and jurisdictions. These determine the extent to which a person possesses the physical, social and personal resources to achieve aspirations, satisfy needs and cope with the environment. Social determinants of health are about the quantity and quality of resources that a society makes available to its members including but not limited to conditions of childhood, income, availability of food, housing, employment and working conditions and health and social services. 7 Groups experiencing low income, low education and other social determinants of health also show higher rates of chronic disease as well as higher rates of complications. Addressing SDOH effectively requires involvement of many sectors beyond health, and in turn an intersectoral approach to delivery of services. Figure 2 above clearly illustrates that the prevalence of diabetes in Central LHIN is highest in the North York West sub-planning area which is also an area experiencing many social determinants of health e.g. poverty. The Central LHIN Health Service Needs Assessment and Gap Analysis (SNAGA) project completed in November 2007 used a combination of quantitative and qualitative data methodologies to identify gaps in both health needs and health service needs in Central LHIN. Figure 3 summarizes the SNAGA conclusions in relation to chronic disease 8. 6 MOHLTC Diabetes Strategy Quick Facts, July 2008 7 Raphael, D. Social Determinants of Health: Canadian Perspectives, Canadian Scholars Press Inc. Toronto, 2004 8 Central LHIN Health Service Needs Assessment and Gap Analysis, KPMG, Toronto, Nov. 2008, CDMP section page 2 CDMP System Level Logic Model March 31, 2009 6

Figure 3 SNAGA Summary of Gaps for Chronic Disease 9 Data indicates there is a shortage of chronic disease prevention programs targeted towards groups at high risk based on ethnicity (e.g. South Asians), low income, seniors 65+, geographically isolated populations There appears to be a lack of sufficient and widely accessible self management programs for chronic diseases, like osteoarthritis Community Health Centres may be one way the LHIN can have an impact on these areas Data suggest there is a need for programs that promote healthy lifestyle as lifestyle can affect the development of multiple chronic diseases (e.g. diet, exercise etc) Chronic conditions are primary managed through family practitioners. The Ontario ratio for family physicians is 80.4 per 100,000 people. The rate for South Simcoe and Northern York is 43.0 per 1000,000 and for York Region planning areas in the low 60s. This may cause problems of access for those trying to manage their chronic conditions. Options for the LHIN are to increase the catchment of the CHCs in areas of need or to work with existing Diabetes Education Centres Data suggests there is a shortage of diabetes healthcare providers to manage the expected growth of diabetics in planning areas with the highest expected growth, such as North York West, South West York and South East York. Data suggest gaps exist among the coordination and integration of chronic services in the LHIN. There are opportunities for system navigation to help clients travel through the system, shared electronic health records, shared care / physician mentoring to build capacity and coordination and the need for inter-professional care. In short, SNAGA recommended more attention to prevention activities and more primary health care services to support the forecasted growth in people with chronic diseases. SNAGA also recommended improving system-level integration and coordination to facilitate patient system navigation. 3. Contextual Factors 3.1 Internal to Central LHIN 3.1.1 Mandate of Central LHIN Local Health Integration Networks (LHINs) were established by the government of Ontario with a mandate to transform the health care system. Fourteen not-for-profit LHINs were established in Ontario with boundaries based on patient health care service usage flow and trends. The 1.7 million residents in Central LHIN cover a geographic area from Eglington Ave (Toronto) to the 9 Central LHIN Health Service Needs Assessment and Gap Analysis, KPMG, Toronto, Nov. 2008 CDMP System Level Logic Model March 31, 2009 7

south, Innsifill Brandford Line to the north, York/Durham Line to the east and Hwy 50 to the west. Health Service Providers managed by the LHINs include: hospitals, long-term care homes, community care access centers, mental health and addictions services and community health centers. The Ministry of Health maintained responsibility for health services including primary care (except Community Health Centres), physicians, ambulances, public health and laboratories. This division of health care services between LHINs and Ministry of Health gives LHINs the ability to redesign the health care delivery system in the acute, post-acute and community domains through collaborative voluntary ventures as well as through formal LHIN/Health Service Provider Accountability Agreements. While this report considers the entire continuum of health services the segments of the health care system which are funded by the LHIN (e.g. acute care) are given more attention. 3.1.2 Integrated Health Service Plan The Central LHIN, along with the other 13 LHINs in Ontario, is under agreement with the Ministry of Health (MOH) to inclusively develop and submit by November 30/09 the second Integrated Health Service Plan (IHSP) identifying priorities for integration between 2009/2010 2012/2013. In January 2009, the MOH identified priorities for IHSPs including Chronic Disease Management and Prevention with a focus on the roll-out of the Ontario Diabetes Strategy. Ideally the CDMP system-level Plan would have been developed in response to the priorities identified in the IHSP however the funding cycle necessitated these two processes being parallel rather than sequential. To facilitate alignment between the CDMP Advisory Network and the IHSP Steering Committee, the Chair of the CDMP Advisory Network is a member of the IHSP 2 Steering Committee. And LHIN CDMP staff work on the internal IHSP 2 team. 3.1.2 Outcome Map The Central LHIN and Faculty of Health at York University are collaborating on a comprehensive evaluation of Central LHIN s health system. The evaluation will focus on health system, population and community health needs. The decision was made to use outcome mapping to clarify strategic objectives, identify enabling outcomes and detail the required supporting actions. Outcome mapping is a new approach for defining and managing completed, multi-stakeholder strategic initiatives. When completed the map becomes a detailed roadmap for execution and provides a framework for performance measurement to confirm that the intended outcomes are actually being achieved. By thinking through the strategy a roadmap for execution and performance measurement is created. Accountability is assigned for every action and implementation is actively managed by monitoring outcomes. Each stakeholder can see exactly where their own contributions complement the contributions of others in achieving the intended LHIN-wide strategic goals. CDMP System Level Logic Model March 31, 2009 8

Once completed, the activities identified in the CDMP Logic Model will be mapped onto the Outcome Map. This will clearly illustrate the link between CDMP activities and the desired LHINwide strategic outcomes. 3.2 External contextual factors 3.2.1 Ministry of Health Chronic Disease Prevention and Management Framework The current health system in Ontario is designed for acute episodic illness rather than long-term chronic disease. The system is based upon clients contacting the system and passively receiving their health care and treatment by the health practitioners. A more responsive system consists of proactive, planned, integrated care where patients are active participants in their own treatment and care. Effective management of chronic disease includes prevention measures to delay onset of the disease and slow progression towards complications. The MOH developed a policy framework to help guide the redesign of health care system to improve chronic disease prevention and management. The Ontario CDPM Framework modifies the Wagner Chronic Care Model (CCM) to include population health and health promotion components such as the social determinants of health and enhanced community participation. The framework consists of eight components: three which address population health: Healthy Public Policy; Supportive Environments; and Community Action; and five components constituting the original Wagner Chronic Care Model: Health Care Organization; Personal Skills and Self-Management; Delivery System Design; Provider Decision Support; and Information Systems. A recent meta-analysis of 112 studies about the CCM assessed whether any of the elements of the model are essential for improving outcomes. The authors found that: No single element of the CCM was essential for improving outcomes; Changes to the delivery system design significantly improved processes and outcomes Self management support significantly improved processes and outcomes; Decision support improved care processes but not outcomes There were no significant benefits from clinical information systems The authors concluded that while there is evidence that single or multiple components of the CCM can improve quality of care, clinical outcomes and healthcare resource use, it remains unclear whether all components of the model and the conceptualization of the model itself, is essential for improving chronic care. 10 Given the evidence available, the MOH framework was used as the foundation for the logic model. 10 Improving Care for People with Long-term Conditions: A review of UK and International Frameworks; NHS Institue for Innovation and Improvement, 2006 ISBN 07044 2584X CDMP System Level Logic Model March 31, 2009 9

4. The Planning Process Two consultants were retained for the CDMP system level strategic plan: Dr. Brian Rush an expert in logic models Dr. Michael Rachlis an expert in health system policy A logic model was used to depict the CDMP system-level plan. It was created in an iterative manner engaging the Central LHIN CDMP Advisory Network, the Planning Subcommittee (a subset of the Advisory Network), the consultants and LHIN staff. See Appendix A for the membership list of the Network. Four meetings of the Planning Subcommittee and two meetings of the full Advisory Network occurred between January to March 2009 to develop the logic model. The staff and consultants met numerous times over the project period to continuously refine the logic model based on stakeholder input, expert opinion and identified evidence. The full Advisory Network also had the opportunity to provide input electronically. 5. The Plan 5.1 Rationale for the Logic model To reach the full potential here in Central LHIN, the MOH CDPM Framework must be communicated effectively where all Health Service Providers (HSPs) easily understand how their unique contributions advance the overall health system redesign process. The logic model serves to illustrate the interdependencies and integration opportunities along the entire continuum of service for chronic disease prevention and management. Logic models are a widely accepted tool within the health sector in Ontario as they are particularly useful for communicating the essential nature and purposes of activities associated with a particular plan. A logic model breaks the plan down into component parts and then specifies the logical and sequential links between the activities or processes to be implemented and the type of longer-term outcomes to be achieved as a result of implementing these activities. In many ways, a well-designed logic model represents the old adage a picture is worth a thousand words. The process of developing a logic model is also widely seen as helpful for clarifying objectives and consensus building, which are especially helpful for implementation and evaluation planning. A logic model describing the many ways in which the various components of the MOH CDPM Framework are implemented depicts the long term strategy for integrating prevention and management of chronic disease within the entire continuum of the health delivery system and infrastructure. The logic model is based on current scientific knowledge, available evidence and international experience. It comprises a set of actions which, when performed collectively by all HSPs within Central LHIN will tackle the growing burden imposed by chronic disease. The aim is to provide an overall direction to support the implementation of HSP plans within LHIN-wide strategies. Given the mandate of the LHIN as a health system manager, the CDMP plan is designed to CDMP System Level Logic Model March 31, 2009 10

support reorientation and strengthening of the health care system, enabling HSPs to respond more effectively and equitably to the health-care needs of people with chronic diseases, in line with MOH and Central LHIN priorities. 5.2 Description of Logic Model Two logic models were produced in this project: System Level CDMP (page 13) and the Delivery System Design (page 17). The top part of the logic model, labeled Components 11 illustrates the three categories within Population Health and five categories within the Chronic Care Model of the MOH CDPM Framework: Population Health o Community Action o Healthy Public Policy o Supportive Environments Chronic Care Model o Health Care Organization o Delivery System Design o Self Management o Provider Decision Support o Information Systems The next level of the model, labeled as Activities and Processes, is comprised of a set of activities and processes within each component that, in turn, contribute to the achievement of the most immediate set of outcomes. These outcomes are identified in the middle part of the logic model as Short-Term Outcomes. For example, after a Health Care Organization assesses its practices and policies in relation to the Accreditation Canada standards for chronic disease, one would expect to see better alignment of organizational policies, practices and strategic directions for CDMP. The bottom part of the logic model consists of the Intermediate Outcomes and Long-Term Outcomes. The Intermediate Outcomes illustrate the three specific outcomes associated with the MOH CDPM Framework: Activated communities and prepared, proactive community partners; Informed activated individuals and families; and Prepared, proactive practice teams. These intermediary outcomes ultimately contribute to the Long-Term Outcomes at both the system level and population level: System Level long term outcomes: o Sustainability of Policy and Health Services; o Quality Services; and o Equitable Access Population Level long term outcome: o Improved Patient Outcomes. The synergy of the system- and population-level long term outcomes is seen as critical to the achievement of the overall LHIN vision of Caring Communities, Healthier People. 11 Components are sets of activities that hang together in the sense they are collectively aimed at selected outcomes, usually undertakes in a similar time period and in some instances, involving the same target audience. CDMP System Level Logic Model March 31, 2009 11

5.3 Description of Activities within the CDMP System Level Logic Model The CDMP System Level Logic Model is a visual representation of the entire scope of work that is required to implement the MOHLTC CDPM Framework in Central LHIN. It is not exhaustive as more activities for each component of the MOHLTC CDPM Framework could be identified, but it does provide at least one activity for each component. While all the activities are identified, they will be prioritized and addressed over many years in a systematic manner. A description of each activity is provided on the following pages. However, the actual implementation plan and performance indicators for each activity will be developed when it is identified as a priority for action. To best describe the various activities within the logic model, the entire CDMP System Level Logic Model (illustrated on page 13) is broken down first into the two large areas: Population Health and Chronic Care Model. It is then further divided into the various components within either Population Health or Chronic Care Model as follows: Population Health: o Community Action o Healthy Public Policy o Supportive Environment Chronic Care Model o o o o o Health Care Organization Delivery System Design Screening Primary Care Acute Care Post-acute Care Community Care Self Management Provider Decision Support Information Systems The Delivery System Design component has been expanded into a separate but cascading logic model consisting of the 5 components listed above. The components for the Delivery System Design address the entire continuum of service from screening through primary and acute care and finally to community care. Each component within either the System Level Logic Model or the Delivery System Design Logic Model is described in terms of activities and the corresponding short term goals. While each component has been described separately, it is important to remember that all components and activities are required to achieve the short, intermediate and long term outcomes identified in the Logic Models. It may be useful to refer to the diagram of the entire logic model (page 13) while reading through the various components. CDMP System Level Logic Model March 31, 2009 12

CDMP System Level Logic Model March 31, 2009 13

Components Community Action Community mobilization leading to establishing new CHCs Healthy Public Policy Short-term Outcomes1-3 year Population Health Activities / Process Objectives Supportive Environment Support advocacy efforts of public health (and others) on built environments Regular updates at CDMP Advisory Network to identify collaboration opportunities Support key messages from the Ontario Chronic Disease Prevention Alliance (OCDPA) Support provincial and local primary prevention and health promotion initiatives Health system partnerships (e.g. with public health) are strengthened leading to more health system integration. Stronger advocacy for healthy public policy Increased awareness by providers/decision makers of role of built environment in Chronic Disease Increased awareness of policies and legislation to support and enable integration across the continuum of service 5.3.1 Population Health Community Action Community Health Centres (CHCs) are non-profit organizations that provide primary health and health promotion programs for individuals, families and communities. A health centre is established and governed by a community-elected board of directors. In July 2008, the Ontario government announced that 22 new CHCs and 17 new satellite CHCs will be supported by 2007-08. More information about CHCs is available in Appendix B. The activity in the Central LHIN CDMP logic model relates to mobilizing community action to encourage the MOH to support either a satellite or new CHC in the northern area of the Central LHIN which SNAGA identified as an area with high levels of Social Determinants of Health. Healthy Public Policy & Supportive Environment People who live in spread-out automobile-dependent neighborhoods are likely to walk less, weigh more and suffer from obesity, high blood pressure and consequent diabetes, cardio-vascular and other diseases compared to people who live in more efficient, higher density communities. The links between health and environment, especially man-made built environment, shows that there is a need for discussion and cooperation between health professionals, urban design professionals and policy makers when it comes to urban planning and design. More information about Built Environments can be found on the website of the Ontario College of Family Physicians at link below. Supporting current advocacy efforts initiated by public health is the first activity identified for the CDMP Advisory Network in this category. http://www.ocfp.on.ca/local/files/communications/current%20issues/urban%20sprawl-jan-05.pdf The CDMP Advisory Network agenda will routinely include updates and presentations by the numerous groups and agencies advancing Healthy Public Policy and Supportive Environments, including but not limited to public health, with the aim of identifying appropriate collaboration opportunities. The Ontario Chronic Disease Prevention Alliance (OCDPA) is a collaborative of health-related organizations working together to focus on healthy living for Ontario in a comprehensive manner. The key messages from OCDPA take a socio-environmental approach to preventing chronic disease framed around a central theme of access and availability to encourage the promotion of healthy eating, physical activity and mental health and the prevention of tobacco use and harmful use of alcohol. All the messages are evidence-based. The activity in the Central LHIN CDMP logic model relates to using these common chronic disease prevention messages in a consistent manner across the CDMP Advisory Network, CLHIN and HSPs. CDMP System Level Logic Model March 31, 2009 14

Chronic Care Model Components Health care Organizations Delivery System Design Self Management (SM) Provider Decision Support Information Systems Activities / Process Objectives HSPs assess their organization using Accreditation Canada CDMP standards Identify system- level and organization supports needed to achieve accreditation criteria Include the concepts of CDMP in the HSP health equity plan (Schedule B) Develop and implement organizational CQI plan & monitor provincial quality improvement initiatives Identify and implement primary and secondary prevention services that address CD Screening: Develop a plan for implementing & evaluating targeted LHIN wide screening for priority populations/health conditions including capacity assessment for care Primary care: Enhance primary care services through multiple complementary strategies (e.g. CHC, FHT, NP-led teams etc) Acute Care: Develop and implement standard multidisciplinary clinical pathway from acute to post-acute to community care Post Acute Care: o Enhance rehabilitation within all relevant diagnostic areas in hospital & community (e.g. PT, OT, SW, RD, etc.) starting with high risk patient groups Community Care: Enhance services provided in community settings including: in-home; LTC, community support services, and others See Delivery System Design Logic Model Identify critical elements of group SM programs Maintain current inventory of SM programs on Community Care Resources Communicate the principles, practices, & benefits of SM across HSP continuum Implement SM supports and programs according to patient stratification o Provide specialized training for SM for professionals and peers o Educate interdisciplinary providers about their role in supporting patient SM o Establish care pathways process and procedures for SM Implement provincial knowledge translation plan for CDMP (e.g. tools, resources, consultation and training) when available Liaise with regulatory colleges regarding CDMP education credits Develop and implement a practitioner/practice CQI plan & monitor provincial quality improvement initiative for opportunities to enhance CQI capacity Develop and provide supports to improve routine implementation of CQI at a practice level within Central LHIN Implement and populate the Provincial Diabetes Registry (including patient and provider views) Resource matching and Referral Solution is implemented Implement ED/CCAC Notification System Engage stakeholders in the development and refinement of information systems Short-term Outcomes1-3 year By 2012 each HSP will have a plan to implement accreditation Canada Chronic Disease standards Better alignment of organizations policies, practices and strategic directions with CDMP systems goals Increased health equity for CDMP Increased prevention services Increased access to primary care Increase proportion of people with CD engaged in appropriate level of service Earlier & better management of patient leading to fewer complications and ED/hospital admissions Improved continuity of care through better coordination and linkages between primary care, hospitals, CCAC and community care Reduced avoidable ED visits Reduced avoidable readmission to hospital Reduced ALC days Increased proportion of people with CD engaged in self-management Increased patient, practitioner, provider, and system-wide capacity for SM (e.g. resources, knowledge, skills) Increased coordination of SM supports between providers Improved awareness & support for evidencebased practice Increased knowledge, attitudes and skills for using CQI to improve practice Reduced gap between recommended and actual practice Improved communication b/w providers Improved resource allocation Information available to patients & provider at any time CDMP System Level Logic Model March 31, 2009 15

Components Health Care Organizations Activities / Process Objectives HSPs assess their organization using Accreditation Canada CDMP standards Identify system- level and organization supports needed to achieve accreditation criteria Include the concepts of CDMP in the HSP health equity plan (Schedule B) Develop and implement organizational CQI plan & monitor provincial quality improvement initiatives Identify and implement primary and secondary prevention services that address CD Short-term Outcomes1-3 year By 2012 each HSP will have a plan to implement accreditation Canada Chronic Disease standards Better alignment of organizations policies, practices and strategic directions with CDMP systems goals Increased health equity for CDMP Increased prevention services 5.3.2 Health Care Organizations Just under 150 Health Service Providers (HSPs) are funded by the Central LHIN, some of which provide services in the area of chronic disease prevention and management. For those that do, the Accreditation Canada standards for populations with a chronic condition, which are built on the pillars of the Chronic Care Model can be used to assess the organization s preparedness to integrate their services for populations with a chronic condition across the continuum amongst various settings and providers. The first two activities in the logic model relate to collaboratively developing a process by members of the Advisory Network to: (a) assess themselves using the accreditation criteria, (b) identify the gaps between the standards and the current practices and (c) identify system-level and institutional supports to achieve accreditation criteria documented within a plan. As appropriate this activity will be added to the Schedule B of the HSP accountability agreements by 2012. Currently hospitals are required to submit a health equity plan as part of their accountability agreement with the Central LHIN. If appropriate, the hospitals may include opportunities to improve the management and prevention of chronic disease in high risk populations within their catchment areas as part of their health equity plans. The forth activity for Health Care Organizations in the logic model consists of enhancing/developing a Continuous Quality Improvement plan specifically targeted at improving the processes and outcomes for patients with chronic disease and where possible aligning the plan to the Ministry of Health quality improvement initiatives. The fifth and final activity in this section of the logic model addresses primary and secondary prevention of chronic disease. The 2007 Ontario Health Quality Council Report estimated that $70million could be saved by the clinical prevention of 33% of new cases of diabetes. Specific evidence based prevention strategies are required across the LHIN to achieve impact. The coordinated and systematic implementation of both primary prevention (CHCs) and secondary prevention (hospitals, community services, others) has the potential of achieving significant impact across the LHIN and reducing the forecasted steep growth in chronic diseases. CDMP System Level Logic Model March 31, 2009 16

5.3.3 Delivery System Design Components Central LHIN Chronic Disease Management and Prevention Logic Model - Delivery System Design March 31, 2009 Screenin Primary Activities/Process Objectives Acute Post Acute LHIN FUNDED Community Care NON-LHIN FUNDED Review existing screening processes & identify strengths and gaps Identify priority populations/health conditions for maximum impact on, for example, population health and healthcare costs Develop a plan for implementing & evaluating targeted LHIN wide screening for priority populations/health conditions including assessment of capacity for care Enhance primary care services provided by CHCs e.g. outreach initiatives to provide mobile CD services in high risk communities such as senior buildings and in LTC Develop engagement strategy for FHTs for CDMP Investigate and facilitate alternate primary care models (e.g., nurse practitioner teamsled teams) Facilitate engagement of clinical specialists with primary care Facilitate patient referral to self-management support and programs as appropriate Facilitate patient referral to clinical specialists as necessary Define high risk patient groups Identify and implement secondary prevention interventions for high risk patient groups Develop and implement standard multidisciplinary clinical pathways (including case management and discharge processes) from acute to post-acute to community care for high risk patient groups Investigate alternate postdischarge notification models/processes between hospitals and primary care Implement one postdischarge model/process to notify primary care for all patients (until provincial ehealth system is functional) Identify rehabilitation services capacity especially for diagnostic groups with unmet rehabilitation needs starting with high risk patient groups Enhance rehabilitation within all relevant diagnostic areas in hospital & community (e.g. PT, OT, SW, RD, etc.) starting with high risk patient groups Establish partnerships with community agencies and train/certify their staff to provide post-discharge rehab services in community settings Establish standard post-acute discharge processes including referral to multidisciplinary community services/agencies Ensure appropriate community linkages and processes established for patients to continue rehab care postdischarge Review available existing community services especially for high risk patient groups Provide comprehensive mix of services in community settings starting with high risk patient groups In-home (e.g., tele-monitoring; routine visits for high risk patients; mandated visits for 75+) LTC (e.g., update admission & discharge policies; enhance capacity to full spectrum of service including primary care & specialists ) Community support services (e.g. transportation) Ensure appropriate communication & linkages between services in community care, primary care & hospitals. Identify services provided in community (e.g. recreation, cultural group programs) Identify opportunities to link between health services & community services Short-term Outcomes1-3 year Intermediate-term Outcomes 3-5 years More people with CD identified at early stages Increased rate of referral & follow-up to appropriate level of care Increased access to primary care for high risk patients and under-serviced populations Increased involvement of CHC s /FHT s/clinical specialists in the early care of CD Earlier & better management of patient leading to fewer complications and ED/hospital admissions Increased referral and follow-up to appropriate level of care Increased proportion of people with CD engaged in appropriate level of service Contribute to Intermediate Outcomes in CDMP Logic Model Increased access to appropriate care for high risk patients o Delay progression of CD o Increased level of preventative & rehabilitation services Improved continuity of care o Better coordination and linkages b/w primary care, hospitals, CCAC and community agencies and services Reduction in avoidable ED visits o Reduce admissions to ED and associated ALC days o Reduced CD-related crises requiring hospitalization Reduced readmissions to hospital Reduced ALC days Long-Term Outcomes 5+ Contribute to Long Term Outcomes in CDMP Logic Model CDMP System Level Logic Model March 31, 2009 17

Components Screening Activities/Process Objectives Review existing screening processes & identify strengths and gaps Identify priority populations/health conditions for maximum impact on, for example, population health and healthcare costs Develop a plan for implementing & evaluating targeted LHIN wide screening for priority populations/health conditions including assessment of capacity for care Short-term Outcomes1-3 year A. Screening The early identification of people at risk for developing a chronic disease permits early intervention and the potential to either avoid the onset of disease or delay the onset of complications. Some screening programs have proven their effectiveness for early intervention (e.g. colon cancer) while other screening programs have produced questionable results (e.g. prostrate cancer). Many screening programs currently exist both in hospital and community settings and the first initiative identified in this part of the delivery system logic model aims to identify the current screening programs available and the evidence-base to develop a robust and focused screening program for chronic disease. Chronic disease is more prevalent in some populations based on different factors including ethnicity, socioeconomic demographics (e.g. poverty) etc. For maximum impact, the screening program should be targeted at a population known for its predisposition to chronic disease and specific criteria developed to identify the potential impact. Once the elements of a screening program are identified and the priority populations selected, a plan to pilot, evaluate, refine and implement the screening program is created complete with staffing requirements and budget. More people with CD identified at early stages Increased rate of referral & followup to appropriate level of care CDMP System Level Logic Model March 31, 2009 18

Components Primary Care Activities/Process Objectives Enhance primary care services provided by CHCs e.g. outreach initiatives to provide mobile CD services in high risk communities such as senior buildings and in LTC Develop engagement strategy for FHTs for CDMP Investigate and facilitate alternate primary care models (e.g., nurse practitioner teams-led teams) Facilitate engagement of clinical specialists with primary care Facilitate patient referral to self-management support and programs as appropriate Facilitate patient referral to clinical specialists as necessary Short-term Outcomes1-3 year Increased access to primary care for high risk patients and under-serviced populations Increased involvement of CHC s /FHT s/clinical specialists in the early care of CD Earlier & better management of patient leading to fewer complications and ED/hospital admissions Increased referral and follow-up to appropriate level of care Increased proportion of people with CD engaged in appropriate level of service B. Primary Care The primary care services funded by the LHIN are provided through Community Health Centres (CHCs) and as explained in the Population Health section above, the LHIN can enhance CHC services as required to address specific issues such as high risk populations for chronic disease. The first activity of this section of the logic model addresses an opportunity to enhance primary care services of CHC through outreach activities in high risk communities e.g. senior buildings The second activity in the section of the logic model proposes outreach and engagement strategies with primary care practitioners (e.g Family Health Teams) with the aim of developing mutually beneficial working relationships. Central LHIN has a number of activities currently underway with primary care including facilitating regular meetings for a Family Physician Advisory Group and the initial movement towards engaging the six local FHTs. Engaging primary care for CDMP will build on these activities. The LHIN is investigating other models of primary care, for example, the LHIN has recommended to the MOH that two Nurse Practitioner Led Teams be funded through the Aging at Home strategy. Other models will continue to be investigated. Evidence demonstrates that the linkages between primary care and specialists improve patient outcomes. The third initiative would identify and distribute a menu of linkage models for consideration by both primary care practitioners and specialists. Patient outcomes can be improved by appropriate referrals to self management supports/programs and clinical specialists. This initiative seeks to provide tools and information to primary care practitioners to help facilitate their ability to make the appropriate referrals. CDMP System Level Logic Model March 31, 2009 19