South East Community Health Centres (CHCs)

Chronic Disease Prevention & Management Network:

An Integrated Approach to CDPM

Carrie Salsbury, Program DirectorGateway Community Health Centre

on behalf of SE CHC CDMP Network

SE CHC CDPM Network• Country Roads CHC

• Gateway CHC

• Kingston CHC

• Merrickville CHC

• Susan Turnbull

• Carrie Salsbury

• Mike Bell (Chair)

• Ray Elgersma

Ministry Messages – growing prevalence and burden of chronic

illness in our population– CDPM that is based on quality improvement

principles, teams and clinical practice guidelines is supported

– Strategies that demonstrate improved care and health outcomes for population with CD

– Acknowledgement of CHC success with team & guidelines-based care

LHIN Messages– Data confirms population is aging, chronic disease is

increasing– Significant health care capacity and cost/sustainability

concern– LHIN wants change that promotes improved access

to integrated approaches, is team-based, promotes measureable health outcomes & contains system costs

– Priority areas include primary care systems, ehealth tools and connectivity, regional program continuums

– Focus from Ministry is diabetes as first round

SE CHCs CDPM Network Purpose 2008-10

To Establish: • Collaborative partnerships among CHCs with a focus on

Increasing Service Quality and Evidence Based Practice

• Common CDPM indicator framework

• Collaborative Partnership CDSMP – Living Well with Chronic Conditions

• Stroke Prevention- improve processes to recognize and address common risk factors in primary health care. Increase uptake of HP practice by PHC providers

Long-Term Outcomes

• Reduced burden of chronic disease for clients & the health care system

• Reduced complications, preventable ER & specialist visits

• Improved quality of life for clients with chronic conditions

Network Areas of Focus

1. Self Management

2. Stroke Prevention Strategy

3. Indicator Development

1. 1. SELF MANAGEMENTSELF MANAGEMENTLiving Well…

With Chronic Conditions

A SE CHCs Chronic Disease Self-Management Collaborative Program

OBJECTIVES

• Increase number of individuals with chronic illness receiving training in self management skills

• Increase number of individuals trained to deliver the Stanford SM Program

• Establish structure and processes to coordinate and maximize existing resources

• Establish regional plan for CDSMP

CDPM Achievements

Self Management • Network includes 16 organizations (CHC’s

FHT’s & CSS • 10 Master Trainers• 29 Staff Leaders• 17 Lay Leaders• 250 participants (CHC only)• 12 sessions completed for 2009/10 (CHC only)

• Creation of common data base for group evaluation

Where are we going ….

• Continue to educate, develop common marketing strategies to recruit participants

• Strengthen relationships with non CHC partners and create support network for Self Management leaders

• Develop & maintain a regional training schedule• Investigate the potential for a regional license • Investigate development of a regional website • Evaluation – beyond self efficacy to include:

healthy behaviour, health status and health utilization data

2. 2. STROKE PREVENTIONSTROKE PREVENTION

Project Goals:• To increase awareness of risk factors of stroke • To increase the uptake of health promotion

concepts by primary health care teams • To improve outcomes / reduce risk for clients by

identifying risk, providing education & referral to health promotion and community prevention resources

Evaluation Methods

• Review and analyze project documents – proposal, progress reports, group feedback forms

• Review and analyze evaluation tools and indicators

• Semi-structured interviews with health promotion champions, providers and clients (21 total)– Pre and post provider surveys– Pre and post client surveys– Project intervention chart summaries

Achievements

Primary Prevention

• Common risk assessment screening tool for stroke

• Provider survey • Motivational interviewing training for over 90

practitioners • Client education tool kit • Developed clinical pathways for primary and

secondary prevention

What did the project achieve?• Uniqueness means distinctive strengths and

challenges across sites

• No easy roll up of results and numbers

• Limitations of evaluation tools

• Highlight common results across sites in three areas: for providers, for clients, for CHCs

% of Men over age 40 with a BP measurement in a 24 month period

Timeframe: April 1 2008 to March 31 2010  Num Den YTDGCHC 859 1041 83%MDCHSC 818 1052 78%CRCHC 723 969 75%KCHC 356 441 81%

Timeframe: Oct 1 2007 to Sept 30 2009  Num Den YTD GCHC 758 1104 69%MDCHSC 741 1131 66%CRCHC 567 1063 53%KCHC 324 918 35%

Numerator:  Primary care male clients, with an active status, over 40 years of age who had a BP measurement recorded in a clinical note using Purkinje.

Denominator:  Primary care male clients, with an active status, over 40 years of age.

Calculation:  Numerator divided by denominator times 100.

Indicator: % of Woman over age 50 with a BP measurement in a 24 month period

Timeframe: April 1 2008 to March 31 2010  Num Den YTDGCHC 753 827 91%MDHSC 787 936 84%CRCHC 677 853 79%KCHC 339 399 85%

Timeframe: Oct 1 2007 to Sept 30 2009  Num Den YTDGCHC 667 922 72%MDCHSC 739 1069 69%CRCHC 563 962 59%KCHC 289 705 41%

Numerator: Primary care female clients, with an active status, over 50 years of age who had a BP measurement recorded in a clinical note using Purkinje. Denominator: Primary care female clients, with an active status, over 50 years of age. Calculation: Numerator divided by denominator times 100.

% of Men over age 40 with a lipid profile in a 24 month period

Timeframe: April 1 2008 to March 31 2010  Num Den YTDGCHC 622 1041 60%MDHSC 715 1052 68%CRCHC 600 969 62%KCHC 228 441 52%

Timeframe: Oct 1 2007 to Sept 30 2009  Num Den YTDGCHC 564 1104 51%MDCHSC 608 1131 54%CRCHC 413 1063 39%KCHC 158 918 17%

Numerator: Primary care male clients, with an active status, over 40 years of age who had a lipid profile measured and recorded in a clinical note using Purkinje. Denominator: Primary care male clients, with an active status, over 40 years of age. Calculation: Numerator divided by denominator times 100.

Timeframe: April 1 2008 to March 31 2010  Num Den YTDGCHC 528 827 64%MDHSC 654 936 70%CRCHC 537 853 63%

KCHC 238 399 60%

Timeframe: Oct 1 2007 to Sept 30 2009  Num Den YTDGCHC 475 922 52%MDCHSC 590 1069 55%CRCHC 387 962 40%KCHC 157 705 22%

% of Woman over age 50 with a lipid profile in a 24 mth period

Numerator:  Female clients, with an active status, over 50 years of age who  had a lipid profile measured and recorded in a clinical note using Purkinje.Denominator:  Female clients, with an active status, over 50 years of age.Calculation:  Numerator divided by denominator times 100.

Timeframe: April 1 2008 to March 31 2010  Num Den YTDGCHC 1369 2991 46%MDHSC 1551 3491 44%CRCHC 740 2,767 27%KCHC 477 2155 22%

Timeframe: Oct 1 2007 to Sept 30 2009  Num Den YTDGCHC 2458 2946 83%MDCHSC 3410 3959 86%CRCHC 965 2752 35%KCHC 432 2873 15%

Clients over age 18 with obesity screening in 24 month period

Numerator:  Primary care Clients, with an active status, over 18 years of age who had obesity screening done and recorded in a clinical note using Purkinje.Denominator:  Primary care clients, with an active status, over 18 years of age.Calculation:  Numerator divided by denominator times 100.

Results for providers• Increased awareness of community resources 

Results for providers

• Increased referrals to CHC programs or community resources

Results for CHCs

The project intended to touch:• Interdisciplinary primary health care

teams - increased use of health promotion concepts

• Clients – better outcomes and reduced risk

• CHCs/Organizations – new and more effective ways (systems, practices, norms) to do health promotion that will continue after the project

Results for CHCs

• Mixed impact on ongoing health promotion practices from high to low on a continuum

Highest ongoing impact in CHCs who began with

a plan to integrate project activities into

ongoing work and who used both individual and

group approaches

Lowest ongoing impact in CHCs who used a

group approach only and did not effectively link individual clients with primary care providers

3. 3. INDICATOR DEVELOPMENTINDICATOR DEVELOPMENT

Varying approaches to evidence based practices in an interdisciplinary model that involves:• individual and group sessions•community capacity building•broad based prevention strategies

Quality Improvement in Primary Quality Improvement in Primary Health Care Service DeliveryHealth Care Service Delivery

•PDSA Cycle: model assists primary health care teams to:

•think about a problem for change

•design and test smaller focused changes

•adopt changes that work into practice on a larger scale

•move on to the next problem

• Helps teams to think and work together on problem solving, setting goals, managing emotions/interactions

SE CHCs Common CDPM Framework – Diabetes Continuum

Improved clinical, functional and population outcomes

Activated communities & prepared,

proactive community partnersPrepared,

proactive, practice teams

Adapted from MOHLTC Ontario’s CDPM Framework, Nov. 2006 LHIN think Tank CDPM

Supportive Environments

• Affordable housing•Food security•Affordable recreation

Community Action

•Exercise programs•Food security/good food box•REACH•Lay Lead CD SMP

Healthy Public Policy

Anti-smoking legislation•Income security, affordable housing, employment protection

Health System(Health Care Organizations)

Delivery system Design

•Interdisciplinary teams•Diabetes clinic•Planned appts & quarterly testing/goal setting•Diabetes education program•Referrals to DEP, CDSMP, exercise programs, with monitoring & follow-up

Provider Decision Support

•Current CPG formally embedded in daily practice•Key indicators reports (CDA CPG)•Alerts & reminders in Purkinje development•CPOE, ECR, paper when necessary

Information Systems

•Patient registry•Recall/reminders•Info access to all team members• Alerts & reminders in Purkinje•ECR, eLabs, paper when necessary•

Community

Personal Skills & Self-Management

Support

•Information & education with physician•Information & education with RN/NP/RD in clinic•Diabetes Education•Stanford CD SMP

Informed, activated,Individuals& families

Productive interactions and relationships

SEISUG – South East Information User Group

•support achievements of SE CDPM Network

• Developed a standardized evaluation tool to measure outcomes of current CDPM initiatives

• queries using the Hummingbird BI application tool extract results directly from the Purkinje database

% of primary care clients with the following chronic diseases

% of active diabetes clients

Numerator: # of active primary care clients with diabetes between age rangeDenominator: Total # of primary care clients at CHCCalculation: = # of diabetic clients / Total # of primary care clients*100

Inclusion Criteria: diabetic clients between age 18 and 75 with an active status and are registered to a physician or a nurse practitioner. Exclusion Criteria: Does not include clients registered to a personal development group or a community initiative. 

As of September 30, 2009CHC Num Den YTDGCHC 247 3713 7%MDCHSC 229 4481 5%CRCHC 264 3514 8%KCHC 225 3698 6%

As of March 31 2010CHC Num Den YTDGCHC 245 3766 7%MDHSC 243 4607 5%CRCHC 276 3533 8%KCHC 227 3758 6%

SE CHC Average: 6.5%

SE CHC Average: 6.5%

Numerator: # of active diabetic clients with an HbA1C test  less than or equal to 7Denominator: Total diabetic clients who have had an Hb1C test in past 6 monthsCalculation: = active diabetic clients with HbA1C test in past 6 months and a result <=7*100

         Total active diabetic clients who have had a HbA1C test

Inclusion Criteria: between 18 and 75 with an active status and are registered to a physician or a nurse practitioner. The result code description contains HbA1C and the result must equal or be less than 7.Exclusion Criteria: does not include clients solely registered to a personal development group or CI.

% of DM clients with HbA1C result less than 7

April 1 2009 to March 31 2010  Num Den YTDGCHC 124 213 58%MDHSC 197 251 78%CRCHC 151 217 70%KCHC 74 148 50%

April 1 2009 to September 30 2009  Num Den YTDGCHC 92 184 50%MDCHSC 99 152 65%CRCHC 140 197 71%KCHC 44 102 43%

% of DM clients with a self-management goal in past yearNumerator: # of diabetic clients with a self-management goalDenominator:# of active primary care clients with diabetes between 18 and 75Calculation: = # of diabetic clients with a self management goal *100

              total # of diabetic clients

Inclusion Criteria: between 18 and 75 with an active status and are registered to a physician or a nurse practitioner. Exclusion Criteria: does not include group clients. Limitations/ Data Quality Issues:  Self-management is a recent concept integrated into CHC's. DMC's have struggled with where to place this information in the client chart to ensure that results can be reported, which has taken some time. 

April 1 2009 to March 31 2010  Num Den YTDGCHC 41 245 17%MDHSC 6 251 2%CRCHC 119 276 43%KCHC 0 247 0%

October 1 2008 to September 30 2009  Num Den YTDGCHC 13 247 5%MDCHSC 3 229 1%CRCHC 104 264 39%KCHC 0 225 0%

% of DM clients with LDL < 2.0Numerator: # of active diabetic clients with LDL less than 2Denominator: Total active primary care diabetes clients between age range with LDL result

Calculation: =               # of DM clients with LDL result <2 * 100         Total active diabetic clients with a LDL test completed within timeframe

Inclusion Criteria: diabetes clients between 18 and 75 with an active status and are registered to a physician or a nurse practitioner with at least once LDL result. Exclusion Criteria: does not include clients solely registered to a personal development group or CI.

April 1 2009 to September 30 2009  Num Den YTDGCHC 71 149 48%MDCHSC 71 151 47%CRCHC 60 132 45%KCHC 23 84 27%

April 1 2009 to March 31 2010  Num Den YTDGCHC 70 154 45%MDHSC 99 197 50%CRCHC 101 216 47%KCHC 37 139 27%

Achievements

Quality Improvement • Common indicators developed for

diabetes and hypertension

• Developing common data definitions, data queries to extract information from EMR to support analysis and quality improvement

• Developing capacity to link impact of SDOH on health outcomes

CDPM NETWORK ACHEIVEMENTS

• Common vision and purpose • Common LHIN wide approach to and

implementation of Best Practice Guidelines • Regional indicator development and evaluation • Embedding Self Management into primary care

practice • Embedding health promotion into primary care

practice

Questions and Discussion!

Contact Us

• Carrie Salsbury – Member SE CHC CDPM Network

Gateway CHC

(613) 478-1211 Ext 246

csalsbury@gatewaychc.org

• Laura Cassidy – Chair SEISUG

Gateway CHC

(613) 478 -1211 Ext 298

lcassidy@gatewaychc.org