CALASS 2006 Implementing Integrated Models of Prevention & Management of Chronic Illness Care: Barriers & Facilitators in the Canadian Context Jean-Frédéric Levesque, MD, PhD Debbie Feldman Caroline Dufresne Pierre Bergeron Brigitte Pinard Annual Research Meeting - AcademyHealth Washington June 8th 2008

Jean-Frédéric Levesque, ARM Washington, 2008 A chronic care transition Increase in life expectancy/Reduction of lethality –Ageing –Increase in prevalence of chronic illness Multi-factorial problems –common determinants –interaction of morbidities –multiplicity of actors involved

Jean-Frédéric Levesque, ARM Washington, 2008

Implementation of the CCM Doctors reporting: –well prepared for managing of chronic illness: 55% –capacity to generate list of patients by diagnoses: 26% –tests are sometimes/often repeated because results are not available: 20% –receiving almost all information on references: 62% Patients reporting: –reception of a self-management plan: 33% –receiving reminders for preventive services: 38% (Source : Commonwealth Fund 2007)

Jean-Frédéric Levesque, ARM Washington, 2008 Patient Assessment of Chronic Illness Care in PHC organizations in Quebec: –33%-41% across types of PHC organizations « What are the obstacles or facilitators to the implementation of integrated models of prevention and management of chronic illnesses? » Problem and question (Source : Levesque, Feldmand et al. 2008)

Jean-Frédéric Levesque, ARM Washington, 2008 Interview/coding grid –Synthesis of CCM and WHO performance framework components Literature review –50 papers on implementation of integrated models Experts consultation –12 experts – semi structured interviews –Regional decision-maker, researchers, analysts Content analysis and coding Research method

Jean-Frédéric Levesque, ARM Washington, 2008 Lack of information systems in clinical settings –Barriers to understanding service provision and to the integration of clinical decision-support tools; Absence of an organizational body –responsible for establishing clinical guidelines and continuum of care protocols; Payment models favouring acute care and unplanned services instead of chronic care; Principal barriers

Jean-Frédéric Levesque, ARM Washington, 2008 Lack of public coverage of multidisciplinary services; –or mobilisation of professionals to primary care clinics Poorly organized primary care; –not benefiting from a structure enabling a proactive approach to illness management Absence of an evaluation culture and tools to assess performance and feedback on performance towards quality improvement. Principal barriers (2)

Jean-Frédéric Levesque, ARM Washington, 2008 Emergence of organizational models compatible with PHC group practice (Family Medicine Groups, Network Clinics); –Gradual improvement in clinical management capacities Progressive integration of health care system institutions and planned implementation of local health networks; –Possibility of contractual agreements on continuum of care Principal facilitators

Jean-Frédéric Levesque, ARM Washington, 2008 A well-developed community sector and a strong institutional basis – Local Community Health Centers; –Supporting the medical and professional network A well-developed public health sector having identified chronic illnesses as a priority in its services program. –Integration of health promotion and prevention in PHC settings? Principal facilitators (2)

Jean-Frédéric Levesque, ARM Washington, 2008 Conclusion Low levels of implementation of CCM in Canada Structural barriers should be removed in order to improve chronic illness management –Payment methods, performance culture, PHC organization, lack of computerization Recent opportunities emerging –New models of PHC, community-based services, system integration Need to address system factors that can impede implementation of CCM

Jean-Frédéric Levesque, ARM Washington, 2008 Institutional and financial support Thank you!