GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORK

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GREY BRUCE CHRONIC DISEASE PREVENTION AND
MANAGEMENT FRAMEWORK

• IMPLEMENTATION TOOL KIT

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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

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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 strategiesTo engage
  ministry stakeholders in a systematic approach to
  addressing chronic disease

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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

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What Makes People Healthy / Unhealthy?
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The Transformation

• TO
• Wellness orientation
• 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

• FROM
• Illness orientation
• prevention not a priority
• a solo provider approach
• Provider, disease centred
• reactive and episodic care
• limited role for individuals in self management

A System Involving Health Care Organizations Indiv
iduals and Families Communities
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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

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WHAT IS THE KIT?

• Written and electronic resources that help groups
  understand the framework, and develop practical
  applications for it
• Step-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

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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

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OVERVIEW OF FRAMEWORK APPLICATION THE WORKFLOW
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CDMP 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
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Step I REVIEW THE OCDPM FRAMEWORK DIAGRAM
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STEP 2 REVIEW THE ELEMENT DEFINITIONS IN THE
OCDPM DIAGRAM
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• 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

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• 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 )

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• Personal Skills Self-Management Support -
  empower individuals to build skills for healthy
  living and coping with disease
• emphasizing the individuals 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)

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• 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)

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• Provider Decision Support - integrate
  evidence-based guidelines into daily practice
• easily accessible clinical practice guidelines
  (e.g. web-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 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 in client
  population with diabetes)

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• 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)

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• 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)

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• 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)

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• 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)

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STEP 3REVIEW THE LOGIC MODELS
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Mission
A systems approach to provide integrated chronic
disease prevention and management services
Roles and Responsibilities
Components
Community Capacity and Integration
Individual and Family Capacity
Health Care Organization
Health Promotion
Roles Responsibility
Roles Responsibility
Roles Responsibility
Primary Prevention
Secondary Prevention
Tertiary Prevention
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STEPS 4-7 BUILDING YOUR PROGRAM
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Developing Logic Models
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• A VALUABLE REFERENCE FOR PROGRAM PLANNING USING
  THE LOGIC MODEL APPROACH
• Innovation Network, Inc. (2005) Logic model
  workbook
• www.innonet.org info_at_innonet.org

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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 Stroke
  Program
• Michelle Walter Brockton and Area
  Family Health Team