ORIENTATION SESSION

Strengthening Chronic Disease Prevention & Management

PURPOSE OF THE MEETING

• Why the Tool is being introduced

• How it may be helpful to your group/committee

• Goals of the meeting

OUTLINE

• Regional Context

• How and Why the Tool was Developed

• What the Tool Looks Like– Basic Concepts

– Critical Success Factors for Strengthening Chronic Disease Prevention & Management

– How the Tool Might Be Used

REGIONAL CONTEXT

Add in appropriate info for your region:• Regional strategies or goals for preventing chronic

disease, risk factors and underlying determinants• Framework or model guiding regional chronic

disease prevention and/or management efforts• Relevant stats or targets

– Eg. reducing number of new cases of type 2 diabetes by x %– Eg. increasing % of population eating recommended daily

fruits and vegetables– Eg. increasing access to diabetes education and self-

management program for high risk population group(s)

HOW AND WHY THE TOOL WAS

DEVELOPED

CONTEXT

The importance of reorienting health services towards health promotion, disease prevention, community-based care and chronic disease management has been repeated in every major health report and consultation in the past 10 years, including the Health Council of Canada’s 2006 annual report*

*Health Council of Canada. 2006 Annual Report “Health Care Renewal in Canada: Clearingthe Road to Quality.” Available online at: http://www.healthcouncilcanada.ca

CONTEXT

Moving toward Integrated System for Chronic Disease Prevention and ManagementAddressing common risk factorsIndividual and population health approachesIntersectoral policy, building environments that

support healthReducing inequitiesImproving system integration (policy, planning

and program delivery levels)

CONTEXT

Changing environment Wide range of disease-specific, risk factor-

specific and age-specific strategies Efforts are underway to better align and

better coordinate strategies and services along the full continuum to improve health outcomesto sustain health system

RESEARCH QUESTION

“What are the critical success factors for integration of chronic disease prevention

and management?”

METHOD/APPROACHEvidence-Based

The Tool was developed through:

• Extensive multi-disciplinary researchPeer-reviewed, indexed journal articlesGrey literature (websites)Key InformantsFocus GroupsFour pilots

NS Chronic Disease Prevention Framework

Leadership

Public Policy

Community Capacity and Infrastructure

Knowledge Development and Transfer

Health Communication

INTERFACE: PUBLIC HEALTH AND PRIMARY CARE

Limitations in:Infrastructure and capacity for both areasInterface: integration, coordination,

communication

Opportunities through renewal efforts in primary health care towardsDisease preventionHealth promotionChronic disease management

RESEARCH RESULTS

• A collaborative planning and assessment tool– Eight Critical Success Factors– Guiding Questions for each

THE TOOL

AIMS TO:

• Engage planners and policy-makers in dialogue

• Promote information exchange• Assess current policy, planning and practice• Identify actions, roles and shared

responsibilities for strengthening prevention and management of chronic disease

TARGETS:

• Policy-makers and planners• With shared responsibility for preventing

and/or managing chronic disease• Working in:

– public health– primary care– home care and acute care– non-governmental– non-health sectors

WHAT THE TOOL IS NOT:

• NOT an accreditation-style tool

• NOT a prescriptive tool detailing what should be in place

• IS a resource to stimulate thinking about what better or promising practices “MIGHT” look like

WHAT DOES IT LOOK LIKE?

A TOOL KIT…

– Assessment tool, including worksheets and rating scales

– How-To Guide• Case Studies

ASSESSMENT TOOL

– Purpose and Use of the Tool

– Ideas about who could use it

– Basic Concepts

– Intro to Critical Success Factors

– Worksheets with Guiding Questions

BASIC CONCEPTS

– CDPM Framework

– Building prevention into the health system

– Integration of CDPM

– Collaborative Action

– Capacity-building

INTEGRATED MODELS FOR CHRONIC DISEASE PREVENTION AND MANAGEMENT

NOVA SCOTIA’S Adopted & Adapted CDM Model

HEALTH SYSTEM

Self Management/

Develop Personal

Skills

Delivery System Design/

Re-orient Health Services

Decision Support

Information Systems

COMMUNITY

Build Healthy Public Policy

Create Supportive Environmen

t

Strengthen Community

Action

Activated Community

Informed Activated Patient/ Family

Prepared Proactive Practice

Team

Prepared Proactive

Community PartnersProductive Interactions &

Relationships

Functional & Clinical Outcomes

Population Health Determinants of Health

BUILDING PREVENTION INTO THE SYSTEM

Chronic Disease Prevention and Management Continuum

Well Population

Primary Prevention

At Risk Population

Secondary Prevention

Established Disease Controlled Chronic Disease

•Surveillance of diseases & risk factors

•Promotion of healthy behaviours

•Creation of supportive environments

•Universal & targeted approaches

•Screening

•Case finding

•Periodic health examinations

•Early intervention

•Medication to control

•Universal & targeted approaches

•Treatment and acute care

•Complications management

•Self-management

•Continuing Care

•Maintenance

•Rehabilitation

•Self-Management

Health Promotion Health Promotion Health Promotion Health Promotion

Prevent movement to at-risk group

Prevent progressionTo established disease

Prevent progression to complications and/orhospitalizations

Tertiary Prevention

INTEGRATING OF PREVENTION AND MANAGEMENT

• Better aligning strategies, vision and goals• Linking individual & population-level

approaches• Shared planning to coordinate efforts and/or

resources• Mechanisms to support information-sharing,

communication and coordination• Service-level integration to improve

comprehensiveness, continuity of care

COLLABORATIVE ACTION

– Shared responsibility for CDPM

– Range of stakeholders

– Building system capacity for CDPM requires collaborative action

CAPACITY-BUILDING

– Organizational development

– Workforce development

– Resource allocation

– Leadership

– Partnership development

• Reference: A Framework for Building Capacity to Improve Health, NSW Health, 2001.

CRITICAL SUCCESS FACTORS

CRITICAL SUCCESS FACTORS

1. Common Values and Shared Goals2. Focus on Determinants of Health3. Public Health Capacity and Infrastructure4. Primary Care Capacity and Infrastructure5. Community Capacity and Infrastructure6. Integration of Chronic Disease Prevention

and Management7. Monitoring, Evaluation and Learning 8. Leadership, Partnership and Investment

Common Values and Goals

Leadership,Partnership and Investment

Focus on Determinants of Health

Public Health Capacity/ Infrastructure

EvaluationMonitoring

Learning

Community

Capacity/

Infrastructur

e

Primary Care Capacity/ Infrastructur

e

Integration

Clinical-based

Prevention(Primary

Care)

Chronic Disease

Management(1°, 2°, 3° care)

Population-based

Prevention(Public Health)

ASSESSMENT QUESTIONS

– Cues to help assess current capacity in the Critical Success Factors• Where are we now in our practice?

• What opportunities are there to build capacity/improve practice?

WORKSHEETS AND RATING SCALES

• The assessment questions are also presented in worksheet format. The questions include a rating scale that outlines a possible range of practice for this component of the Critical Success Factor

•  Additional resources and a more complete description of each Factor is also provided in these sections of the Tool.

HOW MIGHT THE TOOL BE USED?

MULTIPLE APPROACHES

– No one right way to use the Tool

– Keep it manageable, e.g.• Do an assessment of all eight critical success

factors, but focus in on a particular risk factor, e.g. obesity

• Choose a few critical success factors to focus on

• Focus on a setting, e.g. workplace and choose the appropriate factors

HOW-TO GUIDE

– The Tool is meant to initiate and guide a process of engagement – it is neither a one-time event, nor an end it itself. To assist in this process, a series of how-to supports have been developed.

– Includes case studies