GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORKIMPLEMENTATION TOOL KIT
WHERE DID THE CDPM FRAMEWORK COME FROM?Wagner (1999)
Barr et al (2002)
Ontario Ministry of Health and Long term CareThe health care system transformation agenda
CDPM Framework - PurposeTo provide a common policy framework to guide efforts toward effective prevention and management of chronic diseasesTo guide Ministry transformation initiatives such as:Local Health Integration NetworksPrimary Health Care Renewal, Family Health TeamsPublic Health Renewal - health promotion and prevention initiativese-Health strategy, HHR strategySpecific chronic disease strategies To engage ministry stakeholders in a systematic approach to addressing chronic disease
CDPM Framework: PurposeNot just a model: changes the paradigm for careA way for conceptualizing careA framework for organizing or re-organizing careApplicable to any system, organization or program
What Makes People Healthy / Unhealthy?
TO Wellness orientation
prevention at all points of continuuman integrated, interdisciplinary care team approachpatient centredproactive, complex, continuing careindividuals 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 managementA System InvolvingHealth Care OrganizationsIndividuals and FamiliesCommunities
Why does the CDPM system have that capacity?Focuses on populationsFocuses on longitudinal care (creates a system of prevention and care)Supports coordination of prevention and care along a health continuumRecognizes individuals and communities as partnersOffers early access to prevention and support as well as treatmentOffers 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 onesA 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/redesignEstablish a core stakeholder work groupUse 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 FrameworkStep 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 7Revise Program (Logic Model) Plan as required
Step I: REVIEW THE OCDPM FRAMEWORK DIAGRAM
STEP 2: REVIEW THE ELEMENT DEFINITIONS IN THE OCDPM DIAGRAM
Individuals and FamiliesThe centre of the CDPM frameworkDirect involvement and self management of health and chronic diseases is keyTeam members in prevention and careInformed, person-centred choices for living
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 )
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 teamengaging them in shared decision-making, goal-setting and care planningproviding 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)
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)
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)
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)
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)
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)
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)
STEP 3:REVIEW THE LOGIC MODELS
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.
Prepared, proactive practice teams
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.
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.
More people exhibiting healthy behaviours
Individuals and families at the centre of the care team