11

GREY BRUCE CHRONIC GREY BRUCE CHRONIC DISEASE PREVENTION AND DISEASE PREVENTION AND MANAGEMENT FRAMEWORKMANAGEMENT FRAMEWORK

IMPLEMENTATION TOOL KITIMPLEMENTATION TOOL KIT

22

WHERE DID THE CDPM WHERE DID THE CDPM FRAMEWORK COME FROM?FRAMEWORK COME FROM?

Wagner (1999)Wagner (1999)

Barr et al (2002)Barr et al (2002)

Ontario Ministry of Health and Long Ontario Ministry of Health and Long term Careterm Care The health care system transformation The health care system transformation

agendaagenda

33

CDPM Framework - PurposeCDPM Framework - Purpose To provide a common policy framework to guide efforts To provide a common policy framework to guide efforts

toward effective prevention and management of chronic toward effective prevention and management of chronic diseasesdiseases

To guide Ministry transformation initiatives such as:To guide Ministry transformation initiatives such as: Local Health Integration NetworksLocal Health Integration Networks Primary Health Care Renewal, Family Health TeamsPrimary Health Care Renewal, Family Health Teams Public Health Renewal - health promotion and prevention Public Health Renewal - health promotion and prevention

initiativesinitiatives e-Health strategy, HHR strategye-Health strategy, HHR strategy Specific chronic disease strategiesSpecific chronic disease strategies

To engage ministry stakeholders in a systematic approach to addressing To engage ministry stakeholders in a systematic approach to addressing chronic diseasechronic disease

44

CDPM Framework: PurposeCDPM Framework: Purpose

Not just a model: changes the Not just a model: changes the paradigm for careparadigm for care

A way for conceptualizing careA way for conceptualizing care A framework for organizing or re-A framework for organizing or re-

organizing careorganizing care Applicable to any system, Applicable to any system,

organization or programorganization or program

55

66

What Makes People Healthy / What Makes People Healthy / Unhealthy?Unhealthy?

Estimated Impact of Determinants of Health on the Health Status of the Population

Social and Economic Environment

50%

Physical Environment

10%

Biology and Genetic Endowment

15% Health Care System25%

77

The TransformationThe TransformationTOTO

Wellness orientationWellness orientation

prevention at all points of prevention at all points of continuumcontinuum

an integrated, interdisciplinary an integrated, interdisciplinary care team approachcare team approach

patient centredpatient centred proactive, complex, continuing proactive, complex, continuing

carecare individuals empowered for individuals empowered for

self-management and part of self-management and part of care teamcare 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 InvolvingHealth Care Organizations

Individuals and FamiliesCommunities

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Why does the CDPM system Why does the CDPM system have that capacity?have that capacity?

Focuses on populationsFocuses on populations Focuses on longitudinal care (creates a system Focuses on longitudinal care (creates a system

of prevention and care)of prevention and care) Supports coordination of prevention and care Supports coordination of prevention and care

along a health continuumalong a health continuum Recognizes individuals and communities as Recognizes individuals and communities as

partnerspartners Offers early access to prevention and support Offers early access to prevention and support

as well as treatmentas well as treatment Offers multi-disciplinary, multi-sectoral Offers multi-disciplinary, multi-sectoral

strategiesstrategies

99

WHAT IS THE KIT?WHAT IS THE KIT?

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

Step-by-step support to apply the framework Step-by-step support to apply the framework to your existing programs, or build new onesto your existing programs, or build new ones

A way of establishing a common perspective A way of establishing a common perspective and language between partners when and language between partners when undertaking new strategies related to undertaking new strategies related to chronic disease prevention and managementchronic disease prevention and management

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HOW DO WE USE THE KIT?HOW DO WE USE THE KIT?

Identify the current or potential program, Identify the current or potential program, project or partnership initiative requiring project or partnership initiative requiring development/reassessment/redesigndevelopment/reassessment/redesign

Establish a core stakeholder work groupEstablish a core stakeholder work group Use the resources, references, and steps Use the resources, references, and steps

outlined in the tool kit as process supports outlined in the tool kit as process supports for developmental activitiesfor developmental activities

1111

OVERVIEW OF FRAMEWORK OVERVIEW OF FRAMEWORK APPLICATION: THE APPLICATION: THE

WORKFLOWWORKFLOW

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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 ModelsApplying 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 Step I: REVIEW THE OCDPM FRAMEWORK DIAGRAMFRAMEWORK DIAGRAM

1414

INDIVIDUALS AND FAMILIES

Improved clinical, functionaland population health outcomes

HEALTH CAREORGANIZATIONS

Informed, activatedindividuals & families

Prepared, proactivepracticeteams

Activated communities &

prepared, proactivecommunity

partners

HealthyPublicPolicy

SupportiveEnvironments

CommunityAction

DeliverySystemDesign

ProviderDecisionSupport

InformationSystems

Ontario’s CDPM Framework

Productive interactions and relationships

PersonalSkills & Self-Management

Support

1515

STEP 2: REVIEW THE STEP 2: REVIEW THE ELEMENT DEFINITIONS IN ELEMENT DEFINITIONS IN

THE OCDPM DIAGRAMTHE OCDPM DIAGRAM

1616

Individuals and FamiliesIndividuals and Families The centre of the CDPM frameworkThe centre of the CDPM framework Direct involvement and self Direct involvement and self

management of health and chronic management of health and chronic diseases is keydiseases is key

Team members in prevention and careTeam members in prevention and care Informed, person-centred choices for Informed, person-centred choices for

livingliving

1717

Health Care Organizations -Health Care Organizations - make systematic efforts make systematic efforts to improve prevention and management of chronic to improve prevention and management of chronic disease:disease:

• strong leadership (e.g., CDPM champions)strong leadership (e.g., CDPM champions)

• alignment of resources, incentives (e.g. Admin alignment of resources, incentives (e.g. Admin support, IT support for providers, etc.)support, IT support for providers, etc.)

• accountability for results (e.g., set goals, measure accountability for results (e.g., set goals, measure effectiveness in improving outcomes for clients, effectiveness in improving outcomes for clients, population and system )population and system )

1818

Personal Skills & Self-Management SupportPersonal Skills & Self-Management Support - empower individuals to - empower individuals to

build skills for healthy living and coping with disease:build skills for healthy living and coping with disease:

• emphasizing the individual’s and families’ central role in their health, emphasizing the individual’s and families’ central role in their health,

and as a member of the care teamand as a member of the care team

• engaging them in shared decision-making, goal-setting and care engaging them in shared decision-making, goal-setting and care

planningplanning

• providing access to education programs & health information (e.g. providing access to education programs & health information (e.g.

asthma education programs, consumer information)asthma education programs, consumer information)

• behaviour modification programs (e.g. smoking cessation) behaviour modification programs (e.g. smoking cessation)

• counselling and support services (e.g. self-management support groups)counselling and support services (e.g. self-management support groups)

• integration of community resources (e.g. referral to community physical integration of community resources (e.g. referral to community physical

activity programs)activity programs)

• follow-up (e.g. reminders, self-monitoring assistance)follow-up (e.g. reminders, self-monitoring assistance)

1919

Delivery System Design - Delivery System Design - focus on prevention and, improve focus on prevention and, improve access, continuity of care and flow through the system:access, continuity of care and flow through the system:

interdisciplinary teams (e.g., FHTs with defined roles & interdisciplinary teams (e.g., FHTs with defined roles &

responsibilities)responsibilities)

• integrated health promotion and disease prevention integrated health promotion and disease prevention

(e.g., nutrition and physical activity counselling)(e.g., nutrition and physical activity counselling)

• planned interactions, active follow-up (e.g., care paths, planned interactions, active follow-up (e.g., care paths,

case management)case management)

• adjustments, innovations in practice (e.g., group office adjustments, innovations in practice (e.g., group office

visits, central appointment booking service)visits, central appointment booking service)

• outreach and population needs-based care (e.g., Latin outreach and population needs-based care (e.g., Latin

American Diabetes)American Diabetes)

2020

Provider Decision Support Provider Decision Support - integrate evidence-based - integrate evidence-based

guidelines into daily practiceguidelines into daily practice:: easily accessible clinical practice guidelines (e.g. web-based, interactive)easily accessible clinical practice guidelines (e.g. web-based, interactive)

• tools (e.g. disease/risk assessment, management flow sheets, drug tools (e.g. disease/risk assessment, management flow sheets, drug

interaction software)interaction software)

• provider alerts and reminders (e.g. reminders for tests, examinations)provider alerts and reminders (e.g. reminders for tests, examinations)

• access to specialist expertise (e.g. team social worker; cardiologist at access to specialist expertise (e.g. team social worker; cardiologist at

tertiary care centre)tertiary care centre)

• provider education (e.g. working in interdisciplinary teams, provider education (e.g. working in interdisciplinary teams,

collaboratives)collaboratives)

• measurement, routine reporting/feedback, evaluation (e.g. continuous measurement, routine reporting/feedback, evaluation (e.g. continuous

quality improvement loop for target blood glucose levels in client quality improvement loop for target blood glucose levels in client

population with diabetes)population with diabetes)

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Information Systems Information Systems – are essential for enhancing information – are essential for enhancing information for providersfor providers

to provide quality care; to provide quality care; for clientsfor clients to support them in managing their disease to support them in managing their disease

on a day to day basis; and on a day to day basis; and for integrating servicesfor integrating services across health system: across health system:

electronic health records (e.g. personal health information, test electronic health records (e.g. personal health information, test

results, prevention and treatment plans)results, prevention and treatment plans)

client registries to identify and provide patient subpopulations client registries to identify and provide patient subpopulations

with proactive care, monitoring, and follow-up (e.g. tracking with proactive care, monitoring, and follow-up (e.g. tracking

systems, automated reminders)systems, automated reminders)

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

information for clients (e.g. health care advice, access to records, information for clients (e.g. health care advice, access to records,

community resources)community resources)

population health data (e.g. demographic, health status, risks)population health data (e.g. demographic, health status, risks)

2222

Healthy Public Policy Healthy Public Policy - develop and implement policies to - develop and implement policies to

improve individual and population health and address inequities:improve individual and population health and address inequities:

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

fiscal, taxation measures (e.g. lowering duty on imported fiscal, taxation measures (e.g. lowering duty on imported

fruit)fruit)

guidelines (e.g. Health Canada food guidelines, screening)guidelines (e.g. Health Canada food guidelines, screening)

organizational change (e.g. flex hours, day care in the organizational change (e.g. flex hours, day care in the

workplace)workplace)

2323

Supportive Environments Supportive Environments - remove barriers to healthy living - remove barriers to healthy living

and promote safe, enjoyable living and working conditions:and promote safe, enjoyable living and working conditions:

• physical environments (e.g. safe air, clean water, physical environments (e.g. safe air, clean water,

accessible transportation, affordable housing, walking accessible transportation, affordable housing, walking

trails, bicycle lanes)trails, bicycle lanes)

• social and community environments (e.g. daily physical social and community environments (e.g. daily physical

activity in schools, seniors programs in community activity in schools, seniors programs in community

centres, on-site health promotion programs in the centres, on-site health promotion programs in the

workplace)workplace)

2424

Community Action Community Action - encourage communities to increase - encourage communities to increase

control over issues affecting health: control over issues affecting health: collaboration between the health care sector and collaboration between the health care sector and

community organizations (e.g. Latin American Diabetes community organizations (e.g. Latin American Diabetes

Program, London ON)Program, London ON)

• effective public participation and intersectoral effective public participation and intersectoral

collaboration (e.g. community members, private sector collaboration (e.g. community members, private sector

and schools providing breakfast nutrition/physical activity and schools providing breakfast nutrition/physical activity

programs)programs)

2525

STEP 3:REVIEW THE LOGIC STEP 3:REVIEW THE LOGIC MODELSMODELS

Policy, Legislation/Regulations, Guidelines, Fiscal and Human Resources, Information Systems

Communities collaborating with HCOs to identify and prioritize issues affecting the health of the population.

Communities championing activities for healthy public policy, and supportive environments.

Community collaboration with HCOs to develop, link and coordinate services and information for individuals and families.

Community information and programs integrated with health care services.

Improved healthy public policies and supportive environments.

More community information and programs integrated with health care services.

Education, counselling, behaviour modification programs, and information for individuals and families to build skills for healthy living and coping with disease.

Care teams with individuals and families at the centre, and engaged in decision making and care planning.

Self-management information and resources accessible and tailored to meet the needs of individuals and families.

Community programs and resources integrated into care.

More people exhibiting healthy behaviours Individuals and families at the centre of the care team, actively

engaged in decision-making, and daily managers of their wellness.

More individuals and families gaining benefits through involvement in self-management

Increased participation in community programs and resources Increased overall satisfaction of individuals and families with the

responsiveness of the health care system to meet their needs

Health promotion, primary, secondary, and tertiary prevention incorporated into care.

Visible leadership, aligned incentives, policies, resources, measurement, and accountability for CDPM system changes.

Interdisciplinary team practices, with links to specialists, where health care providers collaboratively provide patient-centred care in a seamless and coordinated manner.

Integrated electronic information systems with comprehensive, accurate information for providers and individuals to share information & make the best decisions.

Evidence-based tools for prevention, assessment and management incorporating planned interactions, and prompts for follow-up.

Health promotion and prevention integrated across continuum of care. Health care coordinated across the continuum of care, providers and

settings. The appropriate type and number of health care providers working in

collaboration to meet the needs of the individual and family. Care is evidence based and meets the diverse needs of consumers. Care is proactive, and provides for complex and continuing care, with

follow-up and ease of navigation. Integrated information systems with consumer, decision support and

community information.

Components Community Capacity and Integration Individual and Family Capacity and Integration

Short-term outcomes Increased community collaboration with HCOs to identify and prioritize issues affecting health.

Increased community action for healthy public policy, supportive environments to meet the needs of their population.

Increased awareness, linkages and referral to community programs, information, and resources.

Health Care Organization (HCO) and Provider Capacity and Integration

An integrated, coordinated system for the prevention and management of chronic diseases that is proactive, individual and family-centred, and that provides access to quality care by the right provider at the right time in the right place, resulting in improved clinical, functional and population health outcomes

Inputs

Intermediate outcomes

Long-term outcomes Activated communities and prepared, proactive partners

Outputs

Individuals and families have increased skills and knowledge for healthy behaviours.

Individuals, families and providers have improved understanding of their roles as partners on care teams, and consumers are involved in care planning.

More individuals and families have increased knowledge of their disease processes and role as daily self-manager.

Increased knowledge and skills of consumers in self-management.

More individuals and families are aware of and linked to community programs and resources.

Informed, engaged individuals and families

Providers have increased knowledge, skills and tools to incorporate prevention into their practices.

More HCOs promote system change and provide incentives, align policies, resources, measurement, and accountability.

Increased number of interdisciplinary teams, with links to specialists working collaboratively and providing coordinated, patient-centred care.

More providers using electronic information systems and sharing information among team members, their clients, other health providers and settings.

More providers using evidence-based tools, and quality improvement approaches for prevention, assessment and management.

Prepared, proactive practice teams

Vision

Mission A systems approach to provide integrated chronic disease prevention and management services

2626

Mission A systems approach to provide integrated chronic disease prevention and management services

Components

Roles and Responsibilities

Community Capacity and Integration

Individual and Family Capacity

Health Care Organization

Primary Prevention

Secondary Prevention

Tertiary Prevention

Health Promotion Roles

Responsibility

Roles Responsibility

Roles Responsibility

2727

2828

STEPS 4-7: BUILDING YOUR STEPS 4-7: BUILDING YOUR PROGRAMPROGRAM

2929

3030

Developing Logic ModelsDeveloping Logic Models

3131

3232

3333

3434

A VALUABLE REFERENCE FOR A VALUABLE REFERENCE FOR PROGRAM PLANNING USING THE PROGRAM PLANNING USING THE LOGIC MODEL APPROACH:LOGIC MODEL APPROACH:

Innovation Network, Inc. (2005) Logic Innovation Network, Inc. (2005) Logic model workbookmodel workbook

www.innonet.orgwww.innonet.org info@innonet.orginfo@innonet.org

3535

3636

GB-CDPM FRAMEWORK GB-CDPM FRAMEWORK TOOLKIT PLANNING GROUPTOOLKIT PLANNING GROUP

Lynda Bumstead Grey Bruce Health UnitLynda Bumstead Grey Bruce Health UnitNancy Dool-Kontio Southwest Community Care Access Nancy Dool-Kontio Southwest Community Care Access

CentreCentreCathy Goetz-Perry Grey Bruce Victorian Order of NursesCathy Goetz-Perry Grey Bruce Victorian Order of NursesCarolyn Grace Owen Sound Family health TeamCarolyn Grace Owen Sound Family health TeamJessica Meleskie Grey Bruce health networkJessica Meleskie Grey Bruce health networkLisa Miller Grey Bruce Diabetes ProgramLisa Miller Grey Bruce Diabetes ProgramSusan Pouget Closing The Gap Health Care Group Susan Pouget Closing The Gap Health Care Group

Grey BruceGrey BruceMary Solomon Grey Bruce Stroke ProgramMary Solomon Grey Bruce Stroke ProgramMichelle Walter Brockton and Area Family Health Michelle Walter Brockton and Area Family Health

TeamTeam