GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORK IMPLEMENTATION TOOL KIT

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

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 Confidential Draft

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

In fact, these four risk factors are common to many chronic diseases. Although, in the past, we have tended to focus our efforts on chronic disease strategies e.g. stroke, diabetes, this slide illustrates the importance of focusing on addressing the risk factors that contribute to the onset and progression of disease. Confidential Draft

What Makes People Healthy / Unhealthy? Addressing the risk factors is only half the battle. When we look even deeper, we know that health status is not just about the care that is provided by the health system. In fact, the health system accounts for only 25% of health status. Using a population based approach, in which the determinants of health are addressed, will help us achieve better outcomes in CDPM. If we are going to improve the health of the population we also need to take into consideration the Determinants of Health, such as the social and economic conditions that impact peoples ability to be healthy, and respond to health system interventions. Confidential Draft

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 Individuals and Families Communities Confidential Draft

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

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

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

OVERVIEW OF FRAMEWORK APPLICATION: THE WORKFLOW

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

Step I: REVIEW THE OCDPM FRAMEWORK DIAGRAM

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

STEP 2: REVIEW THE ELEMENT DEFINITIONS IN THE OCDPM DIAGRAM

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

strong leadership (e.g., CDPM champions) 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 ) Confidential Draft

behaviour modification programs (e.g. smoking cessation) Personal Skills & Self-Management Support - empower individuals to build skills for healthy living and coping with disease: emphasizing the individual’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) Confidential Draft

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) Confidential Draft

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) Confidential Draft

links (e.g. between team members, care centres) 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) Confidential Draft

legislation, regulations (e.g. smoking by-laws) 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) Confidential Draft

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) Confidential Draft

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) Confidential Draft

STEP 3:REVIEW THE LOGIC MODELS

Roles and Responsibilities 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

Developing Logic Models

A VALUABLE REFERENCE FOR PROGRAM PLANNING USING THE LOGIC MODEL APPROACH: Innovation Network, Inc. (2005) Logic model workbook www.innonet.org info@innonet.org

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