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Chronic Disease Management and Prevention in Canada

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Chronic diseases -- major impact and major problems for Ontario's health ... Cambridge's Grandview Medical Centre and Toronto's Rexdale and Lawrence Heights ... – PowerPoint PPT presentation

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Title: Chronic Disease Management and Prevention in Canada


1
Chronic Disease Management and Prevention in
Canada
  • North West LHIN
  • Thunder Bay September 25, 2006
  • Michael M. Rachlis MD MSc FRCPC
  • www.michaelrachlis.com

2
Outline
  • Chronic diseases -- major impact and major
    problems for Ontarios health care system
  • The Canadian Chronic Disease Model
  • Assessing Ontarios readiness for CDM
  • Canadian Chronic disease management excellence

3
Chronic diseases have a major impact
  • Chronic diseases account for 70 per cent of all
    deaths.
  • Chronic diseases account for more than 60 per
    cent of health care costs.
  • Chronic diseases account for one-third of the
    years of potential life lost before age
    sixty-five.

4
Chronic diseases Common Risk Factors
  • The Social Determinants of Health, especially
    work and life strain
  • Unhealthy behaviours
  • Smoking, other drugs
  • Diet
  • Physical Exercise

5
Green et al Soc Sci Med 2003 57553-60
6
Our health systems problems with chronic disease
  • lt 30 of Canadians hypertensives have their blood
    pressure properly controlled
  • 60 of diabetics have gone gt 1 yr without an eye
    exam or a check for proteinuria
  • 60 of asthmatics are not properly controlled
  • 20 of heart failure patients are readmitted lt
    60 days

7
We could prevent most chronic diseases
  • gt 80 of ischemic heart disease, lung cancer,
    chronic lung disease, and diabetes cases could be
    prevented with what we know
  • This would free up over 6000 hospital beds across
    Canada

8
Each System is Perfectly Designed to get the
Results it Achieves.We designed our health
system to manage acute illnesses, not manage
(much less prevent) chronic ones.
9
http//www.improvingchroniccare.org
10
(No Transcript)
11
Assessing Ontarios Readiness for CDMAssessment
of Chronic Illness Care (ACIC) Version
3.5Http//www.improvingchroniccare.org/ACIC20doc
s/ACIC_V3.5.doc
12
Assessment of Chronic Illness Care
  • Health care organization (6 items)
  • Community linkages (3 items)
  • Self management support (4 items)
  • Decision support (4 items)
  • Delivery system design (6 items)
  • Clinical information systems (5 items)
  • Creating supportive environments
  • Strengthening community Action
  • Building Healthy Public Policies

13
Organization of the Health Care System
  • Overall organizational leadership in CDM
  • Organizational goals for CDM
  • Improvement strategy for CDM
  • Incentives and regulations for CDM
  • Senior leadership
  • Benefits

14
Community Linkages
  • Linking patients to outside resources
  • Partnerships with community organizations
  • Regional health plans

15
Self-management support
  • Assessment and documentation of self-management
    needs and activities
  • Self-management support
  • Addressing concerns of patients and families
  • Effective behaviour change interventions and peer
    support

16
Decision Support
  • Evidence-based guidelines
  • Involvement of specialists in improving primary
    care
  • Provider education for CDM
  • Informing patients about guidelines

17
Delivery System design
  • Practice team functioning
  • Practice team leadership
  • Appointment system
  • Follow-up
  • Planned visits for CDM
  • Continuity of Care

18
Clinical Information Systems
  • Registry
  • Reminders to providers
  • Feedback
  • Information about relevant subgroups of patients
    needing services
  • Patient treatment plans

19
Lack of Prevention
  • No overall provincial health plan
  • No health goals
  • Unarticulated role for health services and public
    health for advancing population health
  • Little coordination of social policy
  • Dont get me started

20
Ontario Chronic Disease Management Excellence
  • Sault Ste. Marie Group Health Centre
  • Congestive Heart Failure
  • Dorval Family Health Team/Oakville CCAC
    partnership
  • London InterCommunity Health Centre diabetes
    project
  • The Sandy Lake Health and Diabetes Project

21
London InterCommunity Health Centre diabetes
project
  • Multiple entry points
  • Multi-lingual
  • Culturally appropriate care
  • Community health workers
  • International health professionals
  • After hours
  • Integrated with Primary care
  • IT support

22
CDM Requires System Change
  • Re-orienting to patient self management
  • Primary Health Care Reform
  • Advanced Access
  • Integration of primary health care with
  • Secondary and tertiary care
  • Public Health
  • Home Care and Palliative care
  • Mental Health
  • Communications and IT support
  • EHR, telephone, and internet

23
Advanced Access Just in Time
  • Cambridges Grandview Medical Centre and
    Torontos Rexdale and Lawrence Heights Community
    Health Centres have gone to same day servicing
  • Saskatoon Community Clinic
  • Penticton, Prince George
  • All of these primary health care centres say that
    AA has increased their capacity to take on new
    patients and do CDM

24
Integrating Specialty Care
  • The Hamilton HSO Mental Health Program increased
    access for mental health patients by 1100 while
    decreasing referrals to the psychiatry
    outpatients clinic by 70.
  • 145 MDs, 85 mental health counsellors, 17
    psychiatrists, 340,000 patients

25
Getting Started on CDM in Ontario
  • Home care partnerships with PHC
  • especially for FHTs and CHCs
  • Home care nursing for everyone gt 65 discharged
    from hospital with a serious chronic illness
  • Patient self management training
  • Learnings from London InterCommunity Health
    Centre diabetes project?

26
Summary
  • Chronic diseases have a major impact on our
    health care system
  • Ontario health system isnt yet ready to manage
    or prevent chronic diseases
  • Canadian versions of the Chronic Disease Model
    can provide guidance
  • Canadian examples of excellence can provide
    inspiration

27
Nows its time for perspiration!
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