Download - National Home Care and Primary Health Care · for primary health care in Canada “Integration of care is a winning solution. The National Partnership Project has shown that all kinds

National Home Care and Primary Health Care Partnership Project

Partnership in PracticeTwo key strategies involving home care yield high impact benefits for primary healthcare in Canada

Production of this document has been made possible by a financial contribution from the Primary HealthCare Transition Fund, Health Canada. The views expressed herein do not necessarily represent theofficial policies of Health Canada.

© The Canadian Home Care Association, March 2006.www.cdnhomecare.ca

The use of any part of this publication reproduced, stored in a retrieval system, or transmitted in any other form or byany means, electronic, mechanical, photocopying, recording or otherwise, without proper written permission of thepublisher and editors is an infringement of the copyright law.

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As President of the Canadian Home CareAssociation Board of Directors, and on behalf ofthat Board, I am very pleased to share with you thisfinal report of outcomes from the National HomeCare and Primary Health Care Partnership Project.As you will discover, the report clearly demonstratesthe important role that home care has to playwithin primary health care when two key strategiesare undertaken – meaningful partnerships withfamily physicians, and expansion of the home carerole to include chronic disease management.

As a contributor to the original Project proposal, itis particularly exciting for me to see what hastranspired over the course of the last three years.There has been much significant learning foreveryone involved in the Project, and there is thepromise of much more to come as we share ourexperiences with other jurisdictions who can tailorthe Project findings to suit their own needs.

This is indeed a challenging time for health care ingeneral, and primary health care renewal inparticular. The enthusiasm of our Projectparticipants to experiment with new models ofintegration and care delivery, however, shows thatwe have the will and capacity to make the changesrequired to make our system the best it can be.The Project also clearly demonstrates that withteamwork (whether between home care and familyphysician partners and their patients/clients, orbetween the Project’s many other contributors) wecan accomplish incredible things.

Barbara KorabekPresident, Canadian Home Care Association

The National Home Care and Primary Health CarePartnership Project has done just what its namesuggests: it has created strong and meaningfulpartnerships between family physicians and homecare case managers.

The bottom line and the real centre of this Project,however, has always been the patient/client. Usingbest practices — which really means thecombination of evidence-based care that best suitsa particular patient/client — the Project successfullydemonstrated a collaborative care process based onteamwork that focused on the needs ofpatients/clients with chronic disease (in particulardiabetes).

Importantly, the Project findings show that thispatient/client population experienced greatersatisfaction with their care, more awareness of andconnection to other health resources in thecommunity, a greater awareness of their own rolein their care, and better clinical results.

But it is also wonderful to observe that there wereother significant benefits for the physician andhome care partners involved in the Project, and forthe primary health care system as a whole. LikeBarbara, I encourage other jurisdictions to lookclosely at the work done through this Project andthe potential it could offer to your own effortsaround integration and chronic diseasemanagement.

Murray Nixon, MD, CCFP, FCFPChair of Project Advisory Board, Past President, Canadian Home Care Association

Foreword

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Table of Contents

Executive Summary 5

Project Primer 12

High Impact Benefits 17

Appendices

A. Acknowledgements 91

B. Objectives & Logic Model 95

C. Endnotes 99

Enhances quality patient/client care

Facilitates patient/client empowerment

Optimizes health human resources

Enhances chronic disease management in the community

Achieves more effective communication and decision making

Reinforces value of system-level case management

Demonstrates potential for improved cost management

Strategies for change

• Align home care case managerswith family physicians throughformalized and structuredpartnership to create healthteams uniquely equipped toprovide optimal patient/clientcare.

• Expand the role of home care inchronic disease management toserve a broader scope of patientswho would benefit from earlierinterventions.

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Executive SummaryPartnership in PracticeTwo key strategies involving home care yield high impact benefitsfor primary health care in Canada

“Integration of care is a winning solution. The National Partnership Project has shown thatall kinds of positive outcomes are possible – for the patient, for health providers, for theCanadian health care system – when there is productive collaboration of the primary andhome care teams.”

Nadine Henningsen, Executive Director, Canadian Home Care Association

The National Home Care and Primary Health CarePartnership Project was a demonstration projectfunded by Health Canada’s Primary Health CareTransition Fund and sponsored by the CanadianHome Care Association. The Project was initiatedin November 2003 and completed in March 2006.The goal was to optimize collaboration betweenhome care and family physicians by strengtheningexisting home care case management roles intreating adults with diabetes. As part of theinterventions, sites adopted evidence-based,preferred practice care protocols for the definedpatient population and agreed on how to managethe care of patients/clients with this chronicdisease. The participants concluded that chronicdisease is a community-based issue where homecare can, and should, play an integral role.

Canada’s health care system is clearly facing manychallenges. Changes in technology, demographics,economics, human resources, and politics are onlysome of the forces impacting health care. As aresult, re-thinking how primary health care isdelivered has become an urgent priority acrossCanada and a challenge that requires new andinnovative thinking.1 Better integration of healthcare services and improved chronic diseasemanagement are two of the tenets of primaryhealth care renewal.2

This report is about the experience of the NationalHome Care and Primary Health Care PartnershipProject (“the Project” or “the Partnership Project”),a two-year initiative funded by Health Canadathrough the Primary Health Care Transition Fundand sponsored by the Canadian Home CareAssociation (CHCA). It is part of the finalevaluation and dissemination phase of the Projectand is designed to present a ‘big picture’ overviewof Project findings, lessons learned and conclusionsdrawn.3 This report on the Project’s findings is notintended as a data-heavy document, because theNational Partnership Project was a demonstrationproject.4 We have learned through the experiencesof our participants – experiences that have beenrelayed to us through surveys, interviews, and somedata collection.

We have a story to share that we think is verymuch worth telling. It’s the words of ourparticipants (presented throughout this document),along with the data that we did gather, that speakvolumes about the Project’s many successes. Wealso want to share our thoughts on aspects of theinitiative that may not have gone as we expected,and the resulting insights we gained en route thatmay be valuable for other jurisdictionscontemplating a similar venture.

We would further emphasize here that thedescriptions you will find in this report are notprescriptive. Our intent is to share new models,key success factors, and important concepts,knowing full well that the front line staff directlyinvolved in any home care and primary health caresetting will know best how to operationalizechange in their own environment.

The targeted readership includes: Projectstakeholders (such as health care policy makers,home care leaders, and physicians), otherjurisdictions interested in pursuing a similarinitiative, and other chronic disease managementprograms. Our hope – to build awareness of theProject now that it is finished, and to share ourlearning and information with other provinces andterritories in order to accelerate the adoption of thisapproach, which we believe is integral to a strongprimary health care system.

The Project was implemented in Ontario andAlberta; the fact that the two sites had verydifferent health systems led to broader learning,thereby creating opportunities for application inother settings in Canada.

The main focus of the Project was to explore howan augmented role for home care - throughcollaborative partnerships with family physicianswithin a chronic disease management model -could address many aspects of the primary healthcare agenda, including access, integration,outcomes, and efficiency, all with a fundamentalfocus on patient-driven care.

The Project goals were designed to achieve greaterproactive patient care with an emphasis onprevention, improved patient empowerment andmore effective use of appropriate health carepersonnel. The priorities included:

• Collaboration and Partnership

• Case Management

• Chronic Disease Management

• Information technology (IT)

What we learned was that home care programshave a definitive and essential role to play inprimary health care so that Canadians are able toachieve better health and a better health caresystem overall. The Project results and experiencestrongly suggest that implementing two keystrategies involving home care – specifically,aligning case managers with family physicians andexpanding the role of home care in chronic diseasemanagement – yields significant benefits forprimary health care in Canada and mostimportantly for patients.

Lessons learnedIn terms of partnership • Reorganizing home care case managers to

align/partner with family physician practicesmakes sense and can happen quite easily andwithout huge costs. It enables the effectiveleveraging of both physician and case managerskills and competencies to the patients’ benefitand the providers’ satisfaction.

• The nature of partnership required to achieveproductive collaboration takes time. It requiresthe development of a trusting relationship,agreement on how best to communicate andwork together, and a mutual understanding ofoptimal approaches to patient/client care inorder to achieve the desired outcomes (e.g.using care algorithms).

• System barriers are minimized and transitionsacross that system are more seamless whenpartners work together, understand eachother’s context, and strive to jointly makedecisions about best utilization of limitedhealth care resources.

• The partnership model has broad applicationserving a wide range of patient/clientpopulations.

• Without exception, physicians who haveworked in partnership with a home care casemanager do not want to revert back to thetraditional relationship.

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In terms of expanding the scope of home carein chronic disease management • Home care has a role to play within chronic

disease management. By providingpatients/clients with access to a wide range ofcommunity based services, patient/clientconfidence, self-care and clinical outcomes areimproved (for example, A1C levels may bereduced). This is critical for curtailing the costlycrises that arise without effective proactivecare.

• Health promotion and illness preventionstrategies to keep patients/clients well(including strategies to prevent prematuredeterioration in those with chronic disease)need to be considered equally important toillness treatment.

• Team based care with shared accountability ismore effective. Physicians can confidentlydelegate certain aspects of care to home carecase managers, thereby ensuring best care fortheir patients. Case management at a systemslevel – where all health professionals (andpatients) can contribute their respective skills,strengths, and perspectives – is greatlyenhanced as a result.

• Focusing on system wide health outcomespositions home care, along with other sectorswithin health care, to determine itscontribution and accountability and measuresuccess as it applies to a patient/clientpopulation and the overall system.

Project participants were extremely positive aboutthe Project experience itself and what theexperience suggests on an even wider scale.

Numerous benefits that positively impactpatients/clients, providers and the health caresystem were realized. By aligning home care casemanagers with family physicians and expanding therole of home care in chronic disease management,we found that our model:

• Enhances quality patient/client care

• Facilitates patient/client empowerment

• Optimizes health human resources

• Enhances chronic disease management in thecommunity

• Achieves more effective communication anddecision making

• Reinforces value of system-level casemanagement

• Demonstrates potential for improved costmanagement

DoabletransformationThrough a review of each of the high impactbenefits above, it will become clear to readers thatthe key strategies we are proposing constitute ado-able transformation. They are not expensive,they do not take a particularly long time – but theycan have profound impact. The notion ofpartnership in health care, furthermore, is certainlynot new – there are many other examples ofsuccessful partnerships (lots of which areinterdisciplinary in nature5) that contributesignificantly to the Canadian health care system.What is different in terms of the Project is theparticular kind of arrangement we are proposingbetween home care case managers and familyphysicians, and the particular focus (chronicdisease) for their partnership.

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The approach we’re advocating requires awillingness to try new roles and relationships, and italso requires some political will to commit to a newpath. In order for this approach to be successful,the Canadian Home Care Association offers thefollowing recommendations:

• Case management needs to be regarded as anoverall strategy that is central to primary healthcare in Canada. To that end, the contributionof both physician and home care partners tothis strategy should be considered a firstpriority option when planning health careservices. There must also be a commitment tooperating within a clinical framework whereinthe entire health care team takes responsibilityfor clinical outcomes.

• Chronic disease management must berecognized as a community-basedresponsibility, wherein home care can, andshould, play an integral role. Both resourcesand training are needed for this expanded role.

• More resources and training need to bedevoted to the development of teamwork andpartnership that achieves productivecollaboration amongst the primary health careteam.

• Continued investment in and emphasis(including public education) on the vitalimportance of electronic health records andenhanced health IT systems needs to occur.Progress in these areas must proceed as rapidlyas possible.

• The use of electronic forms and tools (includingalgorithms and minimum data sets) mustcontinue to be a high-priority area for healthproviders. These tools are critically importantas best practice guidelines that help to ensureconsistency and direction for managingpatient/client care, both on an individual andpopulation level.

By implementing the key strategies we propose, thepotential of home care can be realized, particularlyin relation to primary health care renewal andchronic disease management; and most importantlythe patient/client can achieve improved outcomes –clinically and in terms of quality of life.

“I think there are opportunities to takesome of the framework and principles thathave been developed through this Projectand develop some further models in termsof coordination of patient/client care.”

Dr. John Maxted, Associate Executive Director, Health & Public Policy, The College of Family Physicians of Canada,

Member of Project Advisory Board

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“I really think this is thewave of the future… itreduces the burden ofcare and produces betteroutcomes. Quite simply,it’s a very positive moveforward.”

Dr. Chris Bockmuehl, Southwest Medical Clinic, Alberta physician partner

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“This is a systemthat can easily bereplicated acrossthe rest ofCanada.”

Sandra Henderson, Executive Director, Community Care Access Centre of Halton

For readers interested inpursuing models similar tothose in the Project, ourwebsite contains valuablelessons we learned en route.

We invite you to explore, learnand build upon ourexperience...

www.cdnhomecare.ca

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Project goalThe National Home Care and Primary Health CarePartnership Project was a demonstration projectfunded by Health Canada’s Primary Health CareTransition Fund and sponsored by the CanadianHome Care Association. The Project was initiatedin November 2003 and completed in March 2006.

The Project’s three strategic priorities were:

• chronic disease management

• partnerships

• enhanced case management.

Through the Project we were able to facilitate localenhancement of information technology (IT)systems to support the three priority areas above.

With an overarching goal of enhancing theintegration of home care and primary health careservices in Canada, the Project used Transition Fundresources to demonstrate a model in two provincesand then disseminate the findings. The modelfocused on the benefits of partnership betweenfamily physicians and home care case managers,where the roles of both groups were optimized.This was done within a chronic diseasemanagement framework, specifically focusing onpatients with diabetes. As part of the interventionsin the Project, sites adopted evidence-based,preferred practice care protocols.

The choice of diabetes was made because of therigor of research regarding this disease and theunderstanding that if the model works for diabetesit will likely work for other chronic diseases as well.

Project sitesThe Project had two sites — in Ontario (Halton andPeel) and Alberta (Calgary). These sites wereselected based on their progressive work in primaryhealth care and to highlight the applicability of theProject in different health care models withdifferent home care structures and varyingresources. The Project involved thirty (30)physicians collaborating with sixteen (16) casemanagers. Over 940 patients/clients have had theopportunity to benefit from the Project.

What were some of the notabledifferences between the sites?Different health care structuresAlberta has a regionalized model of health care;Ontario has a centrally managed provincial healthcare system, although during the life of the Projecthas been undergoing transition to Local HealthIntegration Networks which will assumeresponsibility for devolved health care managementfrom the province.

Different home care structuresWithin the home care context, case managers inOntario and community care coordinators (CCCs) inAlberta have slightly different roles – specifically,Alberta CCCs provide some direct patient/clientcare whereas Ontario case managers do not.Interestingly, as discussed further below, over thecourse of the Project these roles evolved andchanged.

Project Primer A basic overview of the Project

Different starting pointsThe sites began the Project at different stages. TheCalgary Health Region (CHR) had already startedtwo initiatives — partnership-building betweenhome care services and family physicians, and achronic disease management focus — before thisProject (this Project has benefited greatly from keyfindings and lessons learned from Calgary’sprevious experience). For Ontario, formalizedstructured collaboration between case managersand family physicians is a relatively new paradigmshift from traditional relations between these twogroups. On the other hand, Ontario already had anumber of IT components in place or underdevelopment before the Project started.

It should be particularly noted that because Calgarypatients/clients had already been involved in apartnership model of care previous to the NationalPartnership Project, they would not necessarilyperceive any dramatic changes in the way their carewas delivered over the course of the Project. Theywere, therefore, not part of one of the Project’sevaluation tools — a ‘patient/client survey’ —though it is important to note that they wereearlier surveyed as part of the preceding Calgaryinitiative and the results served as a benchmark forthe National Partnership Project results for Ontariopatients/clients.

Other Project findings for Calgary patients/clientsneed to be seen within this historical context aswell (that is, these patients/clients had beenenrolled in a chronic disease-focused, partnership-based model far longer than the newly enrolledOntario patients/clients). It should be pointed outthat the Calgary starting point also enhanced thediversity of the Project with the inclusion ofpatients/clients at different stages of theirconditions and providers at different stages in thedevelopment of partnerships.

Why was it so valuable to havesuch different sites?One of the strengths of the Project was its capacityto allow the unique features and priorities of eachsite to emerge within the context of a nationalinitiative, thereby contributing to the richness ofthe Project and (eventually) the transferability ofoutcomes to other jurisdictions across Canada.

It was also significant that the different sites wereable to learn from one another. There wasconsiderable knowledge exchange, including visitsbetween sites (at their own expense), which provedto be a very positive side effect of the Project. TheProject intranet site was designed as a ‘virtualmeeting place’ for participants, and also provided acommon resource for the sites and participants.

What were the main initiativeswithin the two sites?In Ontario, the Project sought to move from:

• home care services delivered geographically toan arrangement that ties case managementservices to family doctors’ practices

• a system of centralized intake to home careservices to intake that does a better job inconsidering the family doctor, patient/client,and broader health care team as partners inservice planning

• reactive or episodic interventions to a diseasemanagement approach that is more proactive

• paper based records to using technology toenable effective chronic disease management.

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In Calgary, much of the focus was on how IT couldimprove relationships and initiatives alreadyunderway. Interventions strove to achieve:

• improved and more consistent decision-makingin allocation of resources

• more frequent goal attainment bypatients/clients

• more predictable and consistent interventions

• proactive planning and decreased crisisintervention.

Project participantsThis Project involved a great number of people (seeAppendix A). Clearly, those most directly involvedon a day-to-day basis were the physicians andhome care case managers/CCCs (the ‘partnerproviders’6) who were experimenting with newstyles of collaboration, enhanced chronic diseasemanagement tools, and new IT systems, along withtheir patients/clients who agreed to be part of theinitiative. Project site leaders played pivotal roles inoverseeing the Project at their respective sites.

The Canadian Home Care Association had overallaccountability as Project sponsor; two advisorygroups (an advisory board and a steeringcommittee) lent support and guidance in thisregard.

Evaluation is a critical component for all projectsfunded by the Primary Health Care Transition Fund;in this case, IBM Business Consulting was theProject’s external evaluator. The evaluationframework for the Project, including a logic model,was constructed during the developmental phaseand was modified over time to reflect the realitiesof Project implementation at the sites.Patient/client, provider and public evaluationobjectives were identified, and indicators (a set ofmeasures to demonstrate achievements (or failures)over time for each objective) were established. Toview the Project logic model and a full listing ofProject objectives, please see Appendix B.Workflow Integrity Network (WIN) carried out awork sampling study as part of the Projectevaluation, using a method called FunctionAnalysis™ to “track and quantify” the work ofcase managers, particularly in relation to diseasemanagement outcomes.

External communications, IT, and physicianconsultants were also part of the Project team.Overall Project coordination was the responsibilityof a Project Manager and support staff, withassistance from an implementation team made upof a variety of individuals from many of the groupsjust mentioned.

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"This Project is helping us to re-orienthealth services and put the supports wherethey need to be, empowering both theclients or patients and the caregivers withthe kinds of tools they need to bettermanage chronic conditions.”

Dr. Richard Musto, Executive Medical Director, Southeast Community Portfolio,

Calgary Health Region

Project stages

Stage 1:Developmental/Baseline Work(November 2003 – June 2004)

This was the time when the groundwork was laidfor the key strategies to be implemented throughthe Project, and initial baseline information(including a week of Function Analysis data) wasgathered so that there would be a reference pointfrom which to assess and measure any changesover the life of the Project. Some of the challengesand successes achieved during this period arereviewed in our Partnership in Progress interimreport, and also mentioned in some of the highimpact benefits that follow.

Stage 2: Implementation Phase(July 2004 – December 2005)

This was the period that saw the priority areas ofthe Project in action and the two key strategiesbrought to life. During this stage, Projectevaluators sought to quantify some of the changessince baseline; a Function Analysis was performedin January/February 2005 (Time 1) and again inSeptember/October (Time 2). Significantly, FunctionAnalysis results contributed to changes in bothOntario case manager and Alberta CCC patterns ofpractice, a success story discussed in more detail inour High Impact Benefit on case management.

Stage 3: Dissemination Phase (January – March 2006)

Projects funded by the Primary Health CareTransition Fund are intended to benefit the publicand stakeholders nation-wide. Project organizersare obliged to ensure there is awareness of theirproject's activities and broad dissemination oflearnings.

The final Evaluation Report for the Project has nowbeen completed. Project partners are busyreflecting on their Project experience and howlearnings can be carried forward to future activitiesand relationships. Consideration of how the ITcomponent of the Project will carry forward is alsounderway. And the important task of spreadingthe news about the Project is taking place throughmany channels (including this report, conferences,journal articles, stakeholder meetings, and theProject website) to ensure broad dissemination andawareness of the Project and its outcomes.

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“Patients have improvedtheir blood pressures,fasting blood sugars,and cholesterol. It’sexciting for them and it’sreally exciting for me….You feel like you make adifference in their lives.”

Dr. Corinne Breen, Dorval Family Health Team, Ontario physician partner

HighImpactBenefit

Enhances qualitypatient/client care

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Aligning case managers withfamily physicians, and expandingthe role of home care in chronicdisease management contributesto better quality care forpatients/clients with chronicdisease.

While physicians and case managers/CCCs cancertainly provide quality care on their own, within achronic disease management model upstream careby a team of providers is considered best practice.7

Quality care, in this context, is all aboutpatients/clients working together with their healthcare team: it means ready access to the rightservices when needed (with a particular emphasison proactive rather than episodic care), a morepersonal delivery of health care, increasedopportunity for patients/clients to learn more aboutand be more actively involved in self-care (includingfollowing protocols), and, ultimately, improvedhealth outcomes.

Evidence based guidelinesElectronic templates8 that incorporate evidence-based guidelines are another important contributorto improve consistency, quality, and outcomeswithin a chronic disease management framework.Electronic health records provide easy access to apatient/client’s health information so interrelatedproblems can be better managed and so theprovider has more time to spend on care ratherthan administration.

Diabetes was chosen as the particular Project focuswithin the range of possible chronic diseasesbecause it is recognized that diabetes has generallyaccepted clinical guidelines (based on data fromacross Canada and around the world) that arelinked to clinical outcomes.9 For example, asuitable reduction in A1C10 has been shown todecrease secondary complications in patients withdiabetes, leading to improved cost-effectiveness.11

Since the Project was relatively short term, it wasimportant to have a foundation of provenguidelines and tools on which to build. Further,research has demonstrated that there is animportant role for case management withindiabetes treatment – specifically, that “casemanagement is effective in improving bothglycemic control and provider monitoring ofglycemic control.”12

The premise of the Project was that by partneringhome care case managers with primary carephysicians, patients/clients with diabetes couldreceive better quality care. Specific interventions bycase managers around diabetes care captured bythe Function Analysis portion of the Projectincluded:

• Blood glucose monitoring

• Nutrition education management

• Monitoring a patient/client’s condition

• Retinopathy prevention

• Nephropathy prevention

• Hypertension management

• Dislipidemia prevention

• Cardiovascular prevention13

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Patients/clients working together with theirhealth teams is more effective

We found that...• Aligning a home care case manager with a

family physician’s practice leads to a betterunderstanding of available communityresources, more timely introduction of thoseresources, and an increase in time afforded tothe physician to focus on the complex clinicalaspects of a patient’s condition.

• A partnership approach facilitates seamless andtimely transitions across the health system andencourages preventive care instead of episodiccare.

• The use of standardized tools and guidelines byprovider partners allows them to focus onmutually understood and agreed upon clinicaloutcomes as well as steps to achieve thoseoutcomes.

• The application of a chronic disease model forpatients/clients with diabetes (with a focus onhealth promotion, disease prevention, casemanagement, and teamwork) appears to bevery promising in terms of better healthoutcomes. At the Project’s Calgary site, wherethe chronic disease management model ismore mature because of prior and ongoingfocus in this area, a statistically significantreduction in A1C levels was linked to thismodel and continued to be achieved over theduration of this Project.

Partnerships andcollaborationcontribute to qualitycare.

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Our Experience

From ToBy moving

A non-aligned, undefinedrelationship between familyphysicians and home care

A reactive or episodicapproach to patient/clientcare

Process-based delivery ofhome care services

An established partnership that is built on trust and goodcommunication (including the use of enhanced IT)

A proactive, disease management approach that uses the specialskills and contributions of provider partners as well ascommunity services, and includes a focus on health promotionand patient/client involvement in self-care

Outcomes-based care where home care case managers andfamily physicians work together toward agreed-upon clinicaloutcomes for patients/clients

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From a patient/clientperspectiveBetter health status Compared to results reported by Statistics Canadafor the Canadian population as a whole (where themajority of people with diabetes reported theywere only in fair health14), patients/clients at bothsites were more positive about their health status.Specifically, by the end of the Project there was asignificant increase in the proportion ofpatients/clients who reported their health statuswas “about the same” as one year earlier, anincrease that was largely due to a reduction inthose who reported their status was worse thanone year earlier.15

Reduction in A1CAcknowledging that we cannot attribute a directcausal link, the first two cohorts of Projectpatients/clients in Calgary showed statisticallysignificant reductions in their aggregate A1C levelsover the life of the Project (see ‘More of the story:A1C levels’ at the end of this benefit section).Significantly, these clinical results wereachieved/maintained in Calgary even during achallenging period of implementing new ITsystems.

Reduction in complicationsPatient/client comorbidities linked to their diabetesdeclined over the course of the Project. Whereasover 75% of all Calgary patients/clients in the firstthree quarters had at least one comorbidity, by thelast quarter this figure was reduced to just over50%. Similarly, in Ontario the decrease was from71% to 64%; this was a statistically significantreduction that indicates clinical improvement forthese patients/clients.

Increased accessOpportunities were found to expand the carecommunity for patients/clients; patients/clients werealso provided with information and resources thatare known to have a positive impact on care andhealth outcomes, with a particular focus on self-care.

“By working hand-in-hand with our casemanagers and with the Community CareAccess Centre we can discuss our patients’needs and get feedback in a timely fashion,and that means better care for the patient.”

Dr. Don Collins-Williams, Applehills Medical Group,Ontario physician partner

Our Evidence

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From a provider perspectiveImproved knowledge Physicians and case manager/CCC partners reportedan improvement in their knowledge and skillsbecause of their involvement in the Project (and, inthe case of Calgary, because of the previouspartnership relationship) – clearly a positive result interms of their ability to provide high quality care.

Extra insightAs a result of the partnership and thecorresponding increase in communication with thecase manager, physicians reported that they hadadditional insight into a patient’s condition thatnormally cannot be captured during an office visit.Case managers also said they gained a betterunderstanding about how physicians’ officesoperate. Again, such learning is an importantcontributor to the ability to provide quality care.

More diabetic interventions Function Analysis showed the amount of time thatcase managers/CCCs engaged in diabeticinterventions increased dramatically from baselineand then decreased again somewhat at Time 2. In Calgary, this reflected a conscious decision todelegate interventions to other members of theteam. In Ontario, some of the early interventionswere related to initial assessment (particularly thetime-intensive use of the Diabetic Screeningassessment tool) or time spent establishingmonitoring patterns with patients/clients; as somepatients/clients became more involved in their owncare they required less intervention (see our nextHigh Impact Benefit on patient/clientempowerment for more on this story).

From a system perspectiveBetter community linkagesProject partners were very pleased about how theirpartnership and a chronic disease focus helpedthem provide better quality care for theirpatients/clients through more appropriate andtimely linkages to community services and otherhealth care providers.

Use of chronic disease tools and guidelines Provider partners said that the use of standardizedtools and algorithms has, overall, positivelyimpacted on the care they provide and has led tochanges in their patterns of practice, including theadoption of chronic disease best practices (such ashealth promotion), which ensures consistency intreatment and contributes to the provision ofquality care for patients/clients.

“We really have to be a little moreproactive in primary and secondary caredisease management so that we can useacute care for what it was intended to do.”

Carol Slauenwhite, Primary Care Specialist, Calgary Health Region

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Shared understanding regardingpatient/client outcomesThere is high value in having all team members(including the patient/client) understand whichspecific patient/client outcomes are being soughtand what constitutes progress towards thoseoutcomes. The use of standardized care pathwaysand tools can help everyone focus on what’s mostimportant and ensure a sense of sharedaccountability.

Patient/client interventions in achronic care model evolve overtimeProviders should be prepared for more intensiveinterventions with patients/clients at first, wheninitial assessment and health promotion teaching isthe focus. But given the emphasis of the chroniccare model on self-care, the expectation should bethat this time commitment will reduce aspatients/clients become more active and confidentparticipants in their own care.

A1C is a potential focus forpatient/client educationProject survey results showed that the vast majorityof patients/clients did not know the results of theirlast A1C test. This may point to a potential area forpatient/client education in the future.16 Interestingly,those who did know their A1C results tended tohave a normal result (mean 6.7), perhaps suggestingthat having knowledge of results leads to betterefforts (and success) at self-care.17

“One key element of the Project is theintroduction of algorithms or care pathwaysfor certain chronic diseases. These are basedon best practices and clinical evidence thatshows ‘this is the right way to do it’.”

Bob Morton, former Executive Director, Community Care Access Centre of Peel

Lessons Learned

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Project participants received diabeteseducation so they could be active contributorsto interventions that sought to reduce A1Clevels, the gold standard indicator forpatients/clients with diabetes. The Projectexperience led to several observations,including: positive results are related to thelength of time that diabetic interventions havebeen in place; efforts to ensure regular testingresult in better outcomes; IT systems cansupport patient monitoring (through suchthings as electronic reminders and alerts); andpatients/clients benefit from education aboutA1C levels.

A normal A1C level is below 0.070. According tothe Canadian Diabetes Association (CDA),randomized controlled trials have providedcompelling evidence that long-term complicationsof diabetes can be reduced by tight glycemiccontrol – specifically, intensive treatment regimensaimed at lowering A1C levels toward the normalrange have been associated with a reduction inmicrovascular complications in people with bothType I and Type II diabetes.

Other studies also suggest there are cost savings forthe health system when patients experience asustained reduction in A1C levels.18

One of the Project indicators assessed changes inA1C levels over time for Project patients/clients.

What we discovered• In Calgary, there were positive and statistically

significant results in aggregate A1C levelsmeasured over the life of the Project. Whenfinal A1C test results are compared to earlierresults for the first two Calgary cohorts, therewas an overall rise in the proportion ofpatients/clients who had normal A1C resultsfrom 45% to 52% (with a significance level of0.10). Project participants saw the Calgaryresults as very exciting news.

• In Ontario, no such statistically significantresults were obtained, as the Ontario sample

size was too small. However, reductions inA1C that were achieved are promising,particularly given the Calgary experience.

It is important to emphasize that even smallmovements downward in A1C levels are importantin light of the fact that, as indicated above, suchdecreases have been associated with better healthand reduced health care costs. The Calgaryfindings and the Project experience in generalaround A1C testing have also led us to thefollowing observations:

• The longer patients/clients have been receivinginterventions the more likely they are to havepositive results. This was seen, in particular,with the first cohort of patients/clients fromCalgary who had already been undergoingdiabetic interventions for some time; it isimportant to recall that in Ontario suchinterventions were a new undertaking. TheCalgary site was also very pleased that positiveresults were achieved even during IT transition.

• Measuring A1C levels is an important precursorto managing A1C levels, and the CDArecommends such measurement on a quarterlybasis. The partnership model within a chronicdisease framework can help encourage andenable such regular testing. This wasevidenced at the Calgary site where such amodel had been in place for some time. There,initiatives to collect, analyze and report A1Cresults have been accompanied by intensiveprovider and patient/client education. There isalso a clear expectation that the teamreinforces the importance of the CDA guidelineof quarterly A1C testing. Within thepartnership model, CCCs are involved inmonitoring A1C levels and may remindpatients/clients when tests are required or havethem complete a test before their regularcheck-up with physicians.

The recent introduction of IT tools facilitatesadherence to the testing guidelines byproviding electronic reminders, and positionsthe team to be able to readily issue results topatients/clients.

More of the Story... A1C levels

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In Ontario, the partnership and chronic diseasemanagement models experimented with throughthe Project were new and very much in a state ofevolution in terms of their maturity.

In terms of the Ontario results, as one of ourCalgary physician partners, Dr. June Bergmanexplains, “When you introduce a new model, ittakes three years to actually see changesattributable to that model.” CCAC case managersare system navigators and it has not traditionallybeen their role to monitor or reinforce patient/clientactivity related to specific outcomes; during thecourse of the Project, case managers undertooknew responsibilities for patient care and adopted anew working relationship with physicians. Giventhe magnitude of change in the relatively shortterm of the Project, establishing statisticallysignificant improvements in A1C levels within theProject timeframe simply would not have beenexpected.

Also, the delay in implementation of Ontario’s ITsystem meant that most of the physicians and casemanagers did not have the benefit of electronicreminders/alerts. What both the Calgary historyand the more recent Ontario experience point to ishow IT and provider education are importantenablers for regular A1C testing. We think theoverall Project experience suggests that furtheranalysis would be useful, so that questions such asthe following could be answered: If Ontario had alarger sample size and the Project timeframe hadbeen longer, would it have shown the samepositive A1C trend as seen in Calgary? Were theCalgary results transitory, or can a sustained shift inoutcome be demonstrated?

Certainly it is important to point out that Projectparticipants regard the Calgary data as a wonderfulbuilding block for Ontario that will hopefully serveto trigger even more commitment to partnershipand chronic disease management models of care.

Finally, at Project end 80% of patients/clients inOntario did not know their A1C levels. Assuggested in our lessons learned, this would appearto point to the need for still greater patient/clienteducation in this area. Interestingly, of those whodid know their A1Cs, one-third had a normal resultand the mean result was 6.7 – suggesting acorrelation between knowing the A1C andachieving improved results.

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Reducing A1C levels in the population withdiabetes depends on an approach to carethat is a team responsibility including thepatient/client, home care, and the physician.

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“As a team, we can helppatients understandtheir situation better –so they ask their ownquestions rather thanjust hear a pre-packagedscript of what they mayor may not need.”

Dr. Adrian Gretton, Southwest Medical Clinic,Alberta physician partner

HighImpactBenefit

Facilitates patient/clientempowerment

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Aligning case managers withfamily physicians, and expandingthe role of home care in chronicdisease management helpsempower patients/clients withchronic disease.

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“I see this Project becoming the way we dohome care on a wider scale, where linkages with family physicians allowpatients/clients to have seamless care.”

Lynne McTaggart, Client Services Manager, Community Care Access Centre of Halton

Diabetes is a highly concerning illness. People withdiabetes, compared with those without the disease,are more likely to be hospitalized or ill enough tohave to stay in bed more often over the same timeperiod.19 Diabetes is the seventh leading cause ofdeath in Canada today.

However, research shows that health outcomes areimproved when patients/clients are involved inpersonal health practices that help them to self-manage their diabetes. Patient/client involvementin their own care is a basic principle of chronicdisease management.

A partnership approach supportspatients/clientsWhen case managers and physicians work inpartnership using clinical pathways, patients/clientsfeel empowered and supported to make theprescribed management of their condition apriority.

Case manager intervention can also providepatients/clients with additional support wherebythey can receive more information about their careneeds and the resources available to them in thecommunity. A partnership approach to care canprovide further assistance to patients/clients withdiabetes: Calgary’s previous experiencedemonstrated an improvement in patients/clients’control of their diabetes subsequent to the fullimplementation of a case manager/physicianpartnership.

Finally, the use of clinical algorithms and carepathways is helpful for patients/clients to betterunderstand the course of their condition and itstreatment and monitoring.

PremiseConsistent support from the health care teamleads to increased patient/client involvement

We found that...• Provider partners adapt and make changes to

their patterns of practice to involvepatients/clients in a very active and meaningfulway in their own care.

• Using appropriate tools and guidelines,providers can adopt a best practice approachwhen they recognize a specific patient/clientpopulation and its needs, and they can responddirectly to this group to ensure the best carepossible.

• Patients/clients are more confident in theirunderstanding of their illness.

• Patients/clients are more satisfied with theircare, and appreciate learning about and fromcommunity resources available to them to helpthem with their condition.

Patients/clients aremore satisfied withtheir care.

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Our Experience

From ToBy moving

An episodic, acute-care approach topatients/clients’ disease treatment,where they may fall through thecracks

Patients/clients who are unfamiliar with care guidelines

No consistent use of standardizedtools, data sets or algorithms byproviders

Patients/clients who don’t know where to get help

Patients/clients who don’t knowtheir A1C levels

A chronic disease management model of care, wherepatients/clients are actively monitored and actively contribute totheir own health

Patients/clients who are involved in directing their own care andunderstand the steps involved

Providers who use tools and guidelines as a standard base forclinical care

Patients/clients who have familiarity with the array of resourcesavailable to them

Patients/clients who monitor and understand the significance of their own A1C levels

From a patient/clientperspectiveIncreased confidenceProject patients/clients reported increasedconfidence in the management of their own care.By the time of the final Project survey, nine out often respondents felt they knew enough to makehealthy self-care choices. 84% strongly orsomewhat agreed that they received enough self-care information when they were ill.20

That said, it is also important to note that roughlyone in three patients/clients responded that they“somewhat agreed” with the statements on careexperience and knowledge, suggesting that theirneeds were not being fully met. This would appearto present an opportunity for providers to improvethe sharing of self-care information withpatients/clients. It is important to acknowledgethat the family physician and home care staff werenot the only source of information forpatients/clients as many of them also accesseddiabetic education centres and other resources.Further collaboration with other resources tominimize duplication in the production anddissemination of patient/client information isenvisioned by Project participants.

Better self-managementProject patients/clients showed improvements incontrol and management of their diabetes over thelife of the Project (specifically, keeping their bloodsugar and weight under control, following diet,exercise and medicine regimes, and handling theirfeelings about their diabetes).

The percentage of patients/clients who reported avery good or excellent understanding of certainfactors related to diabetes management(specifically, the role of exercise, treatment andcare, special foot care, prevention of complications,and use of tests for management) also increasedover the Project term. Not surprisingly, those whohad received their education from a diabetes centrehad scores that were slightly higher than patientswho had received their education from othersources, pointing to the important role played bythese other community resources.

Further, there were significant improvements in theproportion of individuals who followed their mealplan and regularly checked food labels forcarbohydrate content among those patients/clientsfor whom follow-up data was available.

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“What is empowering for patients withdiabetes is hearing consistent messagesfrom all their health care providers. Havingheard the same story, they can takeownership of decisions in a much morepowerful and informed way.”

Dr. June Kingston, Trillium Health Group,Ontario physician partner

Our Evidence

Relationship with providersThe final survey of Ontario patients/clients in theProject revealed that 93% agreed they feltcomfortable asking their family doctor questionsabout diabetes. However, most patients/clientsresponded ‘not applicable’ when asked this samequestion about their home care provider. Thesurvey also revealed that while 79% ofpatients/clients were very or somewhat satisfiedwith their overall treatment and care, only 52% feltthis way about treatment and care from their homecare provider; similarly, very few indicated they hadreceived diabetes-related education from theirhome care provider (although there was asignificant increase in the number of patients/clientswho felt their home care provider was open totheir questions and opinions).

We believe these results need to be viewed withinthe Ontario context, where the ‘key strategies’being tested (that is, partnership and chronicdisease management models) were very new. Theresults offer important lessons about patient/clientperception and understanding of what constitutes‘treatment’ and ‘education’ within such models,where both the case manager’s role and thepatient/client’s own involvement are quite differentwhen compared with a ‘traditional’ home careclient/case manager relationship for clients withacute needs. See ‘More to the story – Shifting to anew paradigm for patients: the adult-centredlearning approach’ at the end of this benefitsection.

From a provider perspectiveMore knowledgeable patientsPhysicians reported that Project patients/clients aremore knowledgeable about their condition and aremore active in determining care plans. Project siteleads also relayed anecdotally that physicians felttheir other (non-diabetic) patients benefited fromthe physicians’ own enhanced understanding of theimportance of health promotion and patient/clientself-care.

Different modes of communicationInformation was shared with Project patients/clientsthrough a variety of modes that included face-to-face contact, phone, fax, e-mail, forms, andeducational material. Patients/clients receivedinformation on the status of their condition,services they were eligible to receive, and resourceson diabetes education, health promotion and self-care. Modes of communication were actuallychanged during the course of the Project, alsodiscussed in ‘More to the story – Shifting to a newparadigm for patients: the adult-centred learningapproach’ at the end of this benefit section.

From a system perspectiveBetter use of systemProvider partners expressed the view that whenpatients/clients are empowered with information tobetter manage their own health, they can makemore appropriate choices in their usage of valuablehealth care resources.

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‘Patient empowerment’ maymean something different in achronic disease managementcontext The nature of chronic disease is very different fromacute illness. Patients/clients with conditions suchas diabetes face a life-long challenge that usuallynecessitates fundamental changes to lifestyle.Correspondingly, health care teams need to thinkabout how such patients/clients can best beempowered to cope with such a challenge. Thiscan mean quite a different focus and a differentkind of patient/client involvement than in an acuteor episodic care scenario.

The importance of beingresponsive and flexibleRecognizing and responding to particular needs andcircumstances of a patient/client group – forexample, by adopting a different communicationmode – is an important part of encouraging andenabling those patients/clients to be activeparticipants in their own care.

Patients/clients can shareaccountability for their diseasemanagement

Fully informed patients/clients can and should beresponsible to ensure that the assessmentsdocumented as 'best practice' are followed.

“We know that patients often get confusedif they have providers who give themdifferent information. Having clearalgorithms and making sure that all theproviders are operating from the samepage helps to ensure there is consistentinformation that can be trusted by patientsand their families.”

Jeanne Besner, Director of Research Initiatives in Nursing and Health, Calgary Health Region,


Lessons Learned

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More of the story...Shifting to a new paradigm for patients — theadult-centred learning approach

Patients/clients with chronic disease haveunique needs that require a different caredelivery approach by home care. Compared totraditional home care clients, the Projectpatients/clients were generally younger,healthier, and interested in learning moreabout managing their own care. In response,Project home care partners employed newpatterns of contact (such as using e-mail andtext messaging) to allow for patients/clients toself-direct much of the interaction aroundtheir care. Further, home care staff realizedthat they need to re-think the expectationsthat they establish for this specificpatient/client population.

Insights into the implementation of a newmodel of service delivery Project survey results about Ontario patients/clients’satisfaction with their home care providers (andtheir impression that home care had offeredrelatively little education or treatment arounddiabetes) provide, in our view, invaluable insightsinto what is involved when patients/clients arebrought on board to a new model of chronic caretreatment and delivery.

First, it should be made abundantly clear that thesatisfaction results are not at all reflective oftraditional Ontario home care patients/clients (whotypically respond in an overwhelmingly positivefashion about the care they receive from theirhome care providers).

The results need to be considered within thefollowing context (which, we hasten to point out, isapplicable to both Project sites):

• Patients/clients with chronic diseases tend tohave a higher level of general health and areyounger than traditional home carepatients/clients. They also tend to have agreater interest in health outcomes and areeither engaged in health seeking behaviour, or

are open to learning about such behaviour. Asa result, this population has differentcommunication needs from the home caresystem. Traditional, more intensive home careinterventions are simply not what managementof this group is all about.

“The longer time horizon and fluctuating course ofmany chronic illnesses requires regular interactionbetween caregivers and patients. The IOM [Instituteof Medicine] report described this as a “continuoushealing relationship” and argued for the increaseduse of methods of interaction other than face-to-face visits.” 21

As the quotation above suggests, chronicdisease management is an ongoing effortwhere other modes of interaction besides face-to-face visits are important.

• We believe that the survey results reflect thatthe Ontario Project patients/clients may havenot fully understood how their case managerwould assist them and the kinds of ‘education’he/she would be providing. Much educating,for example, was done during theadministration of the Diabetic Screening Tool,but patients/clients may not have been awareof this — they may have thought ‘education’ issomething more formal, such as informationsessions with the diabetic education centre ortheir family physician. Similarly, they may nothave understood that ‘treatment’ within apreventative/health promotion model can meanongoing monitoring and coordination of othercommunity services.

• This suggests that case managers — whoadmittedly were themselves (through thecourse of the Project) experimenting with avery new model of home care — need to thinkdifferently about how they establishexpectations with this patient/client population.

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Adult – centered learning approachSecond, the results point to the importance of anadult-centred learning approach for patients/clientswith chronic disease. Both sites have recognizedthis, and have instituted new patterns of contactwith this particular population.

In Calgary (where, it is important to recall,patients/clients had been part of a diabetesmanagement program for a longer period of time),CCCs have started to use e-mail and textmessaging to accommodate this distinctpatient/client population, many of whom areworking.

As a result, CCCs now engage in less face-to-facecontact and less outgoing telephone calls withthese clients. CCCs report the change hasimproved access to clients, ensured a more timelyresponse, and is highly regarded by thispatient/client group.

This is an adult-centred learning approach thatencourages greater patient/client autonomy soclients call in to the care team when required, asopposed to CCCs always being the ‘director’ of therelationship.

An interesting corollary to this is that it would beexpected that case manager/CCC contact with anew patient/client within a chronic diseasemanagement program would be more frequent(when initial information about diabetes andresources etc. is provided). However, oncepatients/clients are equipped with this information,the hope is that they are in a position to conductmore self-care management, which does notrequire continuous case manager/CCC intervention.

Certainly this was the case in Calgary, aspatients/clients became more actively involved ininitiating contact about their care, rather thandepending on CCCs to direct all communication.

The bottom line: We need to trulyempower patients/clients so they becomeresponsible contributors and importantmembers of their own health care team.

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“In terms ofcollaboration,1+1=3, becausethe synergyachieved is sosignificant.”

Jan Kasperski, Executive Director, Ontario College of Family Physicians,


HighImpactBenefit

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Aligning case managers withfamily physicians, and expandingthe role of home care in chronicdisease management, whencombined with enhancements to IT,can have significant and positiveimplications for health humanresources.

Health Canada’s Health Human Resource Strategyincludes a focus on ‘Recruitment and Retention’ –that is, encouraging more people to enter thehealth care field and improving working conditionsto keep them there. The Strategy also emphasizes‘Interprofessional Education for CollaborativePatient-Centred Practice’ – that is, changing theway we educate health providers so they areequipped and prepared to work in teams. Such achange in orientation can enable better and fasteraccess to health care for Canadians by connectingthem with the most appropriate member of theteam when they need it, ultimately boosting thesatisfaction of both patients/clients and health-careproviders.22

Health human resource challengesThe human resource challenge in relation to familyphysicians is something with which manyCanadians are all too familiar. Family physicians arethe cornerstone of the primary health care systemand are highly valued by their patients for theexcellent and tireless work they perform. But thereare simply not enough of them. Fewer medicalresidents are opting for General Practice, andyounger family doctors are giving up hospitalprivileges and seeing fewer patients. As oneCanadian health care executive puts it, “We needmore Family Physicians, but we also need muchdeeper changes. We need to re-engage FamilyPhysicians by using their skills more intensivelywithin teams of providers and in new settings…”23

A team approachFragmentation of services is recognized as aparticular challenge for patients/clients withdiabetes and other chronic conditions; working insilos is not an efficient use of scarce health careresources and personnel and makes communicationdifficult. Uncertainty around who shoulders whatresponsibility can be confusing. In contrast,collaboration and specialization within a health careteam enables full skill utilization. And many studieslink teamwork and collaboration to job satisfaction,productivity, quality of work and the well being ofteam members.24

The Project was based on the premise that throughstrengthened partnerships and the support of IT,health human resources are positively impacted(providers feel better about their jobs and retentionis more likely), and on a clinical basis the rightperson is called upon for the right intervention atthe right time.

Through a team approach, health care professionalscan negotiate the overlap of their practices, toeveryone’s satisfaction. Multidisciplinary teamworkis proven to be more effective when members areinformed and have trustworthy lines ofcommunication (both personal and electronic).

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9PremiseStrengthened partnerships positively impacthealth human resources

We found that...• Aligning home care case managers and family

physicians’ practices enables the effectiveleveraging of both groups’ skills andcompetencies so they are much happier abouttheir own work and feel they are able toprovide better care to patients/clients.

• Partners learn to communicate effectively,minimizing interruptions and ensuring promptaccess when appropriate. Through goodcommunication (including enhanced IT systemsand the use of standardized care pathways)team members can have the information theyneed to practice at their best.

• By working together, individual providers cometo better understand their own roles,responsibilities, accountabilities, and capacity.Further, the more that team membersunderstand one another’s roles, the greater thechance for cohesiveness.

• Partnership leads to much better use of eachperson on the team, including the recognitionthat certain people might serve broader ordifferent roles. All partners actually take on a‘case management’ role at different times.

• Many administrative/bureaucratic layers can beeliminated through the use of IT and partners’willingness to work together through trustingrelationships. Partners begin to operate onassumptions of good faith.

• Within a collaborative setting there is a highlevel of enthusiasm for professional educationand knowledge enhancement; providerpartners welcome new learning opportunities.

Partnerships enableeffective leveraging ofskills & competency.

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From ToBy moving

Fragmented delivery of care

Impersonal communication betweenhealth professionals

Less than optimal use of individualhealth care providers’ strengths andabilities

Limited use of electronic tools andrecords

A team-based and integrated approach to decision-making andcare delivery

Trusting partnerships where interaction is based onunderstanding and familiarity

Better use and recognition of contributions by all members ofthe team, leveraging each individual’s unique competencies

Enhanced IT systems (specifically, the use of standardized carepathways) that enable partners to communicate moreeffectively and optimize their individual contributions topatient/client care

Our Experience

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From a client perspectiveImproved collaborationA significant increase was achieved inpatients/clients' perceptions that their home careprovider was open to questions. Most clientsrecognized that their providers were working as ateam, although the survey results suggest room forimprovement.

From a provider perspectiveMore synergyMost of the Project partners expressed that byworking in a team they established greatersynergies within the health care system andgreater efficiencies in providing care topatients/clients.

Skill recognition in self and othersProject partners said that through the partnershipthey felt increased recognition for their knowledgeand skills, as well as an increase in their own abilityto call upon the right team member morefrequently.

Maximizing potentialBy being part of a more focused and streamlineddelivery model where patients/clients had fewer‘channels’ to have to work through, and byestablishing a trusting working relationship withone another, partners were able to maximize theirown potential as health care providers. Themajority of physicians felt more positively abouttheir work life as a result of their partnershipinvolvement with a home care case manager.These physicians do not want to revert back to thetraditional relationship with home care, and agreethat home care case managers are critical to theirpractice. A partner physician in Ontario put it thisway: “It was as early as the very first patient whowas referred to (the CCAC) that it becameapparent that it was a very good thing for ourpractice. I hope the CCAC feels the same way,because I sure hope this continues….”

Case manager/CCC job satisfaction was alsodramatically increased as a result of the partnershiprelationship. Interestingly, case managers andCCCs remarked that the work involved in being apartner was very independent and self-directed,and required them to be flexible and have theability to “think outside of the box”.

Our Evidence

“The members of the partnership teamstend to be happier and more satisfied withtheir jobs, and that’s very important at thistime when we need to both retain andattract health care professionals.”

Jeanne Besner, Director of Research in Nursing and Health, Calgary Health Region,


More collaboration and trustFunction Analysis results and Project surveysindicated that over the life of the Project there wasan increase in the nature and scope ofcollaboration between physicians and casemanagers, and the level of trust increased betweenthese groups.25 Case managers and CCCs actuallyunderwent changes in their roles as a result of theProject experience, a story you can read moreabout in our High Impact Benefit on casemanagement.

From a system perspectiveImproved knowledge and skillsBoth physicians and case managers/CCCs indicatedan improvement in their knowledge and skills inmany areas – for example, understanding oneanother’s roles and scope of practice, gaining ITexperience and capability, and enhancing their useof chronic disease management tools.

Contribution of ITThe increased use of tools and algorithms and theenhancement of IT were regarded as important(though sometimes challenging) contributors tobetter professional relationships, enhancedinformation-sharing among partners, and(ultimately) partners’ ability to provide better care(often involving change in patterns of practice).

Importance of continuing educationProfessional development opportunities were seenas very important and valuable. Ontario casemanagers, for example, said that they increasedtheir knowledge of diabetes management througheducation sessions and collaboration with theDiabetes Education Centre. CCCs in Alberta saidthat the Project provided them with learningopportunities that they otherwise would not havereceived, particularly around IT.

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“Through our partnerships we have theopportunity to talk about some of thesystem issues for diabetic patients. Wehave the chance to share ideas in order toimprove outcomes.”

Lucia Cheung, Client Services Manager, Community Care Access Centre of Peel

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What alignment means Reorganizing the structure of the homecare/physician relationship through alignment— to optimize the work and satisfaction of both

groups — can happen quite easily and withouthuge costs. However, alignment does not meanhiring case managers into the family practice, asthis would only create another layer of bureaucracyand loss of access to the extensive service networkmanaged by home care.

Adapting the model to fit thesituationThe specific nature of provider partnerships cannotbe overly prescribed by participant organizations asit must respect the unique needs, mission, valuesand priorities of each physician practice and homecare office. In other words the partnership modelmust be adapted to different circumstances –indeed, this was the case within the Project itself,where clearly there were differences between sites,and even between locations (Halton and Peel)within one site.

At the outset of the Project, it was also clear thatprospective partner physicians, who were keenlyinterested in finding new and innovative ways toimprove access and quality of care for theirpatients, needed to understand the benefits of thetwo key strategies being tested through the Project.It became evident that a document that set outsome of the roles and responsibilities of physicians,as well as what they would gain from the strategiesbeing proposed, would be a helpful tool whenpartnerships were first being established. Such adocument was, therefore, developed as part of theProject.

Ongoing learning is importantOngoing educational opportunities for providers areessential. The regular chance to acquire professionalknowledge and skills is an important part of beinga member of a vital health care team.

How other health careproviders/services fit into thepartnershipAs will be discussed in more detail in the HighImpact Benefit that follows on enhancing chronicdisease management in the community, it may taketime to sort out the role of other disciplines/serviceswithin a partnership — case managers/CCCs saidthey interacted regularly with these other resources,but physicians expressed the view that keepingpartnerships simple was important (that is, nothaving too many lines of communication).

The challenge of fundingOne challenge related to a collaborative approach isthat the fee-for-service model of compensation forphysicians offers minimal remuneration for a teamapproach to care. It is a reality that organizationsinterested in a partnership arrangement need toinclude physician compensation in their businessmodel, particularly as there is extra physician timerequired at the outset of a partnership when newpatterns and protocols are being established.Similarly, case manager salary time also needs to be‘funded’ in terms of the development workrequired at the outset of a partnership.

Lessons Learned

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More of the story...The five cornerstones for building an effectivepartnership - Team-building, time, trust, tools,and talking

An integrated, team-based approach topatient/client care can produce wonderfulpatient/client outcomes, professionalsatisfaction and efficacy, and system-widebenefits. A collaborative care model functionsbest when trust is established between teammembers. This requires overt effort on thepart of the individuals involved. Using best-practice tools and algorithms can help provideobjective reference points around which tobuild care pathways that are trustworthyresources for all the team members involved.The opportunity to communicate in areciprocal, respectful manner is also a criticalcomponent of good partnership-building.

The Project experience made it very clear that ifworking together can help health professionalseach feel better about their own contribution topatient/client care and the overall health caresystem, certain essential building blocks for suchcollaboration are needed.

Taking the time to build productive collaborationFirst, we found that the case managers andphysicians in our Project needed to be supported todevelop team-building skills. Specifically, team-building initiatives need to be explicitly undertakenright at the outset of a new partnershiparrangement. As Alberta physician partner Dr.Adrian Gretton explains: “we needed to spendtime up front to get the team really working welland that has paid off because each member of theteam feels more in touch with what’s going on…”

It also takes time to achieve the kind of partnershipthat engages in productive collaboration. Newways of doing things do not happen overnight. Forexample, in Calgary CCCs had to make themselvesavailable to physician partners as required to buildtheir relationships, and this often necessitated face-to-face contact at the outset. As relationships grewand trust was established, CCCs did not have tospend as much time meeting with the physiciansand more phone contact occurred.

Evolving partnerships build trustIn Ontario, as partnerships evolved and physicianscame to know and trust their case managerpartner, it was discovered that case managers couldalso liaise with the family practitioner’s nurse asanother alternative to direct contact with thephysician.

Overall, our Project partners discovered that it iswise to limit the amount of change occurring all atonce and important to acknowledge pastachievements. Trust is clearly another absolutelyessential ingredient to a successful partnership.

Such trust is built upon partners understanding oneanother’s roles and determining together howpatient/client care can be best provided in order toachieve desired outcomes.

The use of best-practice tools and algorithms canbe invaluable to provide objective reference pointsand guidelines around which partners can buildstandardized care pathways.

“When you can fully use the skills, critical thinking,and the professionalism that you have, then youdefinitely feel more in control, more empowered,and are able to translate that into results for yourpatients/clients.”

Ann Boucher, Director of Client Services, Community Care Access Centre of Peel

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The results remind us yet again of thehuman element in any partnershipinitiative, and how important it is to beprepared for adaptation and reassessmentto keep the partnership healthy and vital.

Open communication and participatorydecision makingTalking openly about roles, responsibilities, andcommunication mechanisms is critical, as is aparticipatory decision-making process where bothsides feel like valued partners and where individualdifferences are respected. Partners are, after all,people first — as individuals they need to get toknow one another’s style and substance.

As Ontario case manager Jeannette Adlingtonsuccinctly puts it, “What I found was that it all boilsdown to communication between the two of youand you work together as a team… I found that asthe partnership progressed we became morecomfortable with one another and we were able towork more closely together.”

And the payoffs, professionally speaking, can behuge, as Jeanette also attests: “I find that I feelmuch more part of a team and not so much anindividual practitioner out there in thecommunity…”

Finally it should be made clear that partnership isnot an achievement that remains static. It isinteresting to note, for example, that in Calgary(where multidisciplinary partnerships had been inplace for some time) the perspective of CCCs oncollaboration over the life of the Project wasvariable. This could have been attributable toseveral factors, including changes in leadershipwithin their home care program and the CalgaryHealth Region over the term of the Project.

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“The team of the familyphysician and the homecare case managersupports thepatient/client as theylearn about the resourcesin the community andhow to manage theirchronic disease.”

Nadine Henningsen, Executive Director, Canadian Home Care Association

HighImpactBenefit

Enhances chronic disease managementin the community

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Aligning case managers withfamily physicians, and expandingthe role of home care in chronicdisease management positivelycontributes to chronic diseasemanagement.

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A chronic condition is an illness, functionallimitation or cognitive impairment that lasts (or isexpected to last) at least one year, limits what aperson can do, and requires ongoing care.27 Whilepeople are living longer, this also means they oftendevelop at least one chronic condition: During the21st century, chronic (non-communicable) diseaseswill be the leading cause of avoidable illness, healthcare system utilization, and premature deaths.28 Atpresent, half the Canadian population lives withone or more chronic conditions, consumingapproximately 70% of health care resources; 4.6%of Canadians have diabetes.

Chronic conditions and our health care systemUnfortunately, chronic conditions are frequentlyneglected because health care systems areorganized to respond in an episodic fashion toacute illness and injuries. However, research showsthat chronic diseases can be very expensive for thehealth care system, and efforts to stabilize orimprove certain clinical indicators can help controlhealth care expenditures.29

The Canadian health care system needs strategiesto transform its approach to chronic disease. High-quality chronic disease management (a key tenet ofprimary health care renewal) is a proactivetreatment approach focused on communityresources and collaboration among primary careteam members and patients/clients, with anemphasis on outcomes, health promotion,patient/client self-care, and the use of best-practiceguidelines and algorithms.

The Project was based on the view that expandingthe traditional role of home care case managers toinclude chronic disease management – specifically,through partnerships with family physicians – is aneffective primary health care strategy and asustainable approach to managing chronic diseaseacross Canada.

PremiseDisease management is described as ‘casemanagement at its finest’.26

“Through new tracking methods madepossible with enhanced IT, we are able tolook at patients as groups. This can give usvaluable information for the purposes oftreatment and prevention. ”

Pat Reader, Chronic Disease Management Information Manager, Calgary Health Region

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We found that...• Patients/clients are more satisfied with a

proactive treatment approach built oncollaboration.

• Provider partners (case managers andphysicians) feel that being part of a trustingpartnership enables them to confidently usealgorithms for best-practice patient/client care.

• Through a partnership relationship – whereprofessional perspective is shared and decisionsare made together – both home care casemanagers and family physicians are moreinclined to see their actions as outcomes-related.

• Working together, provider partners can ensurethe best use of broader community resourcesfor chronic disease management and there isless fragmentation of care.

• Patients/clients feel good about being activeparticipants in their own care.

• IT is an enabler for provider partners to bettermanage their patients/clients with chronicdisease.

• Physicians express satisfaction at being able tolook at a specific population and introduceproactive measures and not just engage inreactive or episodic care.

System benefits arerealized from effectivedisease managementstrategies.

From ToBy moving

Reactive, episodic interventions

Providers working independently

Patients/clients as recipients of care

Largely paper-based system

A proactive disease management approach where specificclinical outcomes are sought

Partnering home care case managers and family physicians

More integrated and coordinated delivery of service, includingother community resources

Patients/clients as active participants in their own care

Using IT to enable effective and evidence-based chronic diseasemanagement (specifically, the use of clinical algorithms andguidelines) where there is better monitoring of patient/clientclinical data

Our Experience

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From a patient/clientperspectivePatient/client satisfactionBy the time of the final Project survey, close to 80%of patients/clients were very satisfied or somewhatsatisfied with their overall treatment and care —this included the nature of the patient-providerrelationship, the relationship among providers, andthe availability of information, support and follow-up.30

Interestingly, the survey also revealed a smalldecrease in patient/client satisfaction around: theway their providers worked together as a team toensure ongoing support; the way providerscoordinated and communicated regarding careprovided; and diabetes-related services available.This could be because Project partners naturally hadmore interaction at the start of their relationshipboth with each other and with patients/clients, andas processes were more streamlined over timeprovider interaction was still very much ongoing,but not as obvious.

More knowledge In the final Project survey, nine out of tenpatients/clients reported an increase in theirknowledge about where to get support and feltthey had sufficient information about self-care.

From a provider perspectiveAbility to provide better care Provider partners felt that their collaboration led toimprovements in their knowledge, skills and attitude

in providing care to patients/clients with diabetes. Case managers/CCCs received in-service trainingabout diabetes care and treatment, in particularA1C levels, so they could focus on clinicaloutcomes for their diabetic populations. Asdescribed in our High Impact Benefit on quality carefor patients, those outcomes were noteworthy.

Better understanding Provider partners felt that by establishing strongrelationships with one another and understandingone another’s roles, they provided integrated andcohesive care for their patients/clients, built ontrusted information-sharing. This is not to say thatsuch relationship-building was necessarily easy.Both case managers/CCCs and physicians relayedthat at the outset of the Project the expectations ofthem were unclear, however, as the partnershipmodel progressed the expectations were clarifiedand this led to strong working relationships withinpartnership teams. Case managers and CCCs alsohad some initial concerns about being merely seenas extra resources for physicians, but as the teamsevolved and the role of the case manager/CCCbecame clearer to the physicians, the team wasable to function more effectively.

Involvement of wider care communityCase managers/CCCs said they experienced anincrease in the scope of collaboration with abroader care community in chronic diseasemanagement, although the role of some of theseother resources in relation to the casemanager/physician partnership was an area thatwas identified as needing more attention (in termsof structuring these other relationships).31

Our Evidence

“Community-based services for health care willbecome increasingly important as the populationages. This Project helps demonstrate thatcommunity-based services and partnerships work.”

Nancy Milroy-Swainson, Director of Primary and Continuing Healthcare Division, Health Canada

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Building toolsTogether, provider partners have either built onexisting chronic disease management tools (mainlythrough the use of enhanced IT) or created newtools specifically as a result of the Project. Othercommunity partners, such as the Living Well with aChronic Condition Program in Calgary32, have alsobeen involved in this effort.

Providers said these tools have, overall, positivelyimpacted on the care they provide and have led tochanges in their patterns of practice33, including theadoption of chronic disease best practices (such ashealth promotion), which ensures consistency intreatment.34 The experience of Project partners inthis regard is discussed in more detail in ‘More ofthe story: The Importance of tools and protocolsfor partners working in a chronic diseasemanagement model’ at the end of this benefitsection.

From a system perspectiveBetter referrals Physician and home care partners believe theircollaboration has contributed to increased andmore appropriate referrals to other communityservices for patients/clients with chronic disease.This is particularly noteworthy in the case of theCalgary site, as they already had partnershiprelationships in place prior to the Project, so furtherimprovements might not necessarily have beenexpected.

For their part, external stakeholders were positiveabout the collaboration they had with Projectpartners and felt that delivery of patient/client carehad benefited as a result (in particular, referralswere made more efficiently). There wasanticipation that with further enhancement of IT,there would be opportunities for partners toreinforce messaging and advice being offered byother stakeholders (like diabetes education centres).

Appropriate service usage Project partners also believe that a community andteam-based approach to diabetic patient/client carecan help minimize the use of other institutionalservices.35

System benefitsRepresentatives from both provincial ministries ofhealth (Alberta and Ontario) who were surveyedobserved that there has been improvedcollaboration between the home care and primarycare sectors as a result of the Project. Theserepresentatives recognized that the partnershipmodel has allowed for more integration in theoverall health care system.

“I think having an extra person along withme to help patients make changes byimproving their health care and healthstatus makes a big difference.”

Dr. June Kingston, Trillium Health Group, Ontario physician partner

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While the term of the Project may have been tooshort to conclusively demonstrate the benefits(clinical, economic, etc.) of the chronic diseasemanagement model (including IT as an enabler forthat model), the results were highly promising.Project partners were extremely positive about usingthe model; there was also anticipation that ITwould eventually help create a more seamlesssystem and allow for more streamlinedcommunication and data management to enablebetter patient/client care both on an individual andan overall patient/client population basis. The manylessons learned included the following:

Allot time and trainingShifting to a new model of professional interactionand care delivery takes time and requires that allparticipants (providers and patients/clients) aregiven adequate information and training to take ontheir new roles and responsibilities. The timecommitment may be particularly heavy at theoutset, when new patterns and relationships arebeing sorted out, and there needs to be someflexibility around projected timeframes because ofthis. By focusing on ‘early wins’, partners can seethe potential in their new patterns and that it isworth the effort to pursue new directions.Similarly, getting used to new tools and guidelinesalso takes time, and the willingness (wherenecessary) to refine and revise such tools to betterserve both patients/clients and providers.

Keep patients/clients informedabout teamworkAs a partnership evolves, partners may need tostress to patients/clients that while the use of toolsand practice protocols may sometimes make theteam approach seem less obvious, collaboration isstill ongoing in a meaningful way.

Make the commitmentIt is not enough that tools and guidelines are inplace for benefits to be realized, but there has tobe assurance that these tools are being followed.

Awareness and understandingis essentialHealth care partners working with an outcomes-based focus need to receive and understandinformation regarding their mutual activities andoutcomes so they can continually refine and worktogether on best practices to achieve desired endresults; trustworthy and helpful electronic systemscan go a long way to making sure this happens.

Lessons Learned

“This Project has opened doors in thecommunity that hadn’t been opened before,and this has been an important contributionto how the overall system runs.”

Jan Kasperski, Executive Director,Ontario College of Family Physicians,


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Essential to chronic disease management is theuse of best-practice tools and algorithmsenabling providers to work together toachieve the best outcomes for patients/clientswith chronic conditions. Calgary undertookcomputerization of many of its existingresources and introduced new assessmenttools. Halton/Peel achieved changes topatterns of practice as a result ofimplementing new assessment and diseasemanagement tools which were ultimatelycomputerized. The Project experience led tothe recognition that tool development is anevolutionary, ongoing process that may attimes be challenging for providers.

The value of best practice guidelines andalgorithmsClinical protocols and tools are regarded asimportant devices for interdisciplinary teams to usein providing evidence-based care, assuring thequality of that care, and eliminating unnecessarysteps to get that care delivered as efficiently aspossible.36 The use of best-practice guidelines andalgorithms is, as set out in the introductory sectionfor this benefit, a fundamental tenet of the chronicdisease management model. It has beendemonstrated that combinations of various formsof provider education, guidelines and tools formanaging diabetes achieve the greatest outcomesfor diabetic clients.37

Leveraging the expertise of the Project sitesAt the Project outset, the Calgary site was alreadyusing various chronic disease management toolsthat had emerged from previous initiatives (forexample, algorithms based on clinical guidelines tosupport the diabetic patient/client in thecommunity setting). Through the course of theProject other tools were developed and severalexisting tools were refined further, including sharedcare pathways, and there was a shift from a paper-based to computer-based system. The Calgary

team worked closely to develop a minimum dataset that informed the development of the electronicshared care pathways. This work, we understand,is serving to inform other initiatives in the provinceand the Western Health Information Collaborative.

Developing new toolsIn Ontario, the Project CCACs did not have anysuch tools in place for patients/clients withdiabetes, but they had clearly made a commitmentto chronic disease management. The home caresites actually developed a number of tools throughthe course of the Project, including a physicianrequest-for-services form, a case managementintervention report, and a communication log.

Changes to practice standardsSignificantly, changes to standard patterns ofpractice protocols (for example, intakemanagement of physician partner referrals to homecare) have also been initiated within the OntarioCCACs as a result of their involvement in theProject.

An evolutionary processIt is important to point out that tool and protocoldevelopment is an evolutionary process, and oncedeveloped both tools and protocols should notremain static, but need to be regularly reassessedso they reflect current decision making processes,workflow patterns, etc. Certainly this has been thecase within the Project.

More of the story...The importance of tools/protocols forpartners working in a chronic diseasemanagement model

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Site specific requirementsTools also need to be unique to the jurisdictions inwhich they are to be used. The Project participantsare happy to share some of their creations (see ourProject website at www.cdnhomecare.ca for somehelpful tools), but we encourage readers to seehow they may be adapted for their own particularcircumstances.

Accepting and incorporating the use of clinicaltools and guidelines is also not necessarily an easytask. In the case of Calgary, where partners wereexperienced with such tools, the introduction ofenhanced IT solutions (which directly impacted onthe use of the tools) posed various challenges.There was, for example, a decrease in CCCs’satisfaction around the use of chronic diseasemanagement tools at the time of the Project’s finalsurvey, which is likely due to frustrations they hadin relation to implementation of a new regional ITsystem (CDMIS). Providers in Calgary alsoexpressed concern that the CDMIS did not interfacewell with physicians’ systems, which produceddouble documentation.

For additional background about this, see ‘More ofthe story: The Project IT experience’ in our HighImpact Benefit on communication and decision-making. We certainly think it is very significant thatthe Calgary site managed to maintain its clinicaloutcomes even during this time of IT transition.

In Ontario, where there is a shorter history usingchronic disease management tools, some physicianpartners (who did have some tools in use prior tothe Project and considered them effective) reportedthat they did not always use the Project toolsconsistently as they found them quite timeconsuming.

Case managers also initially reported lowsatisfaction regarding the tools and their impact.However, this did increase somewhat over the lifeof the Project, suggesting that once the tools hadbeen introduced case managers gained a betterunderstanding of their effectiveness, but due to thetimeline of the Project (as well as IT challenges)case managers had relatively limited opportunitiesto use them.

The collaborative approach used in the Projectemphasizes the use of good practices thathave been demonstrated throughout thecountry and the world.

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“Partnerships allowphysicians and casemanagers to understandone anothers’ rolesbetter and developcommunicationprocesses to getresources and care tothe client more quickly.”

Joan deBruyn, Director of Home Care, Calgary Health Region

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Aligning case managers withfamily physicians, and expandingthe role of home care in chronicdisease management, with theassistance of better IT, can leadto more effective communicationand decision-making.

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All health care professionals seek to provide thebest quality care possible. Using time efficiently isessential toward that end, particularly in a systemthat now asks more (and more often) fromeveryone involved.

The Project planning team recognized the pivotalimportance of good communication to good care.We also realized that there is a high level offrustration among providers around duplication,copious amounts of paperwork, excessive use ofvoice mail and the resulting lost messages and/orinaccurate information. These challengescontribute to misunderstandings and unfoundedassumptions about the services available forpatients/clients.

When developing the Project, we believed that ifprovider partners developed communicationguidelines and coupled this with practice guidelinesand algorithms, their interactions could besignificantly better: the quantity of unnecessarycommunication would reduce, while the quality ofmeaningful contact would be enhanced.

Not only does better communication make forhappier providers, but it is also critical within achronic disease management context wheremaximizing patient/client self-management isessential. The longer time horizon and fluctuatingcourse of many chronic illnesses entails ongoingmonitoring and cumulative gathering ofinformation regarding patient care and status.38

And this requires regular and effective interactionboth between providers and between providers andtheir patients/clients. Effective information-sharing

rests on good teamwork. Without trustingrelationships in place between providers, it’s easy tolack confidence in data being shared and decisionsbeing made. Further, patient confidence and abilityto self-manage is compromised when information ismissing or inconsistent among the care team.

Research also suggests that health care teams canmake better decisions and communicate moreeffectively if they have a common IT framework inplace. Electronic disease management tools(including clinical practice guidelines or CPGs) areimportant contributors to better planning, bettermonitoring and follow-up, and better patient/clientoutcomes.39

Within the Project framework, it was recognized,even more specifically, that electronic health recordscan provide an essential link between home careand primary health care so providers are able toshare essential information and track patient/clienthealth.

The Project goal, therefore, was to enable moreeffective communication of health information andbetter decision-making through partnerships andenhanced IT.

PremiseGood communication impacts quality care

“Patients are more comfortable knowingI’m in the loop and I’m part of the homecare they are getting.”

Dr. Don Collins-Williams, Applehills Medical Group,Ontario physician partner

We found that...• Partnership is all about working together with

confidence, and depends on robustcommunication both in person andelectronically. In a trusting environment wherepeople communicate effectively (and focus onfinding solutions) bureaucratic barriersdisappear.

• Physicians make increased, and moreappropriate, general referrals to home carewhen they work in tandem with a casemanager. They are able to actively participate inimportant decisions for their patients/clientsconcerning home care services.

• Good communication and joint decision-making by providers working in partnershipleads to better care, better service choices forpatients/clients (both within home care andwithin the community), and better utilization ofscarce resources. Case managers contributetheir understanding of a patient/client’s homesituation and the community resources; family

doctors bring their knowledge of thepatient/client's medical needs. By sharing withone another, and involving the patient/client inthat exchange, they make better care decisions.

• Enhanced IT within a partnership (including useof standardized care pathways and tools) canimprove transfer of information and contributeto better quality care.

• On a larger scale, effective IT can contribute tomore dependable and useful patient/client datathat can allow providers to better understandthe needs of patient/client populations soappropriate proactive measures can beintroduced; this can have positive implicationsfor public health knowledge and initiatives.

Partnerships lead tobetter use of resources.

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From ToBy moving

A lack of familiarity and connectionbetween family physicians andhome care

Home care services deliveredgeographically

Ad hoc and irregular communication

A system of centralized intake tohome care services

A largely paper-based record-keeping system

An established and trusting relationship

Tying case management services (and a particular case manager)directly to a physician’s practice for more streamlined andeffective communication and decision-making

Agreed-upon strategies for regular communication betweenpartners

Intake that involves the family physician, patient/client, andbroader health care team as partners in decision making andservice planning

An electronic system shared by provider partners, using best-practice tools and algorithms

Our Experience

From a patient/clientperspectiveTeamwork The majority of patients/clients surveyed said thatthey felt their providers worked as a team to ensureongoing support for their care (although as notedin our High Impact Benefit on chronic diseasemanagement, this level decreased slightly by theend of the Project — likely reasons for this areexplored in that benefit section). Patients/clientswere also satisfied with the information theyreceived about their diabetes.40

Increased trust Partner providers relayed that trust is more easilyestablished with patients/clients whenpatients/clients are aware the team is working incollaboration. For example, patients often will havelongstanding relationships with their physician andare more likely to trust the case manager/CCC theirphysician knows and communicates with on anongoing basis.

From a provider perspectiveMore contactThe number of case managers per physicianpractice reduced dramatically, allowing partners theopportunity to have more personal and directcommunication.

Function Analysis results41 showed an increase inthe time that case managers and CCCs spentinteracting with physician partners over the life ofthe Project.42

Increase in general referrals to home careProject physicians’ referrals of non-diabetic (i.e.,non-Project) clients to home care increased over thelife of the Project as physicians’ awareness andunderstanding of home care services grew (afinding also discussed in our High Impact Benefiton case management).

Better information sharingProvider partners experienced an increase ininformation-sharing with one another and felt thisfacilitated integration and collaboration of servicedelivery (for example, Calgary CCCs’ time spentwith partner physicians almost doubled betweenbaseline and Time 2). Case managers/CCCsreported that they appreciated receivinginformation about a patient’s history from theirpartner physician prior to conducting anassessment. For their part, physicians indicatedthey appreciated the case manager/CCC’s insightabout a patient’s everyday life (something not oftencaptured during an office visit).

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“The health care system is complex, and itcan be mind boggling for patients. Weneed someone to act as navigator and casemanagers are well equipped and wellprepared for this role. What was missingbefore this Project was the relationship withprimary care physicians. ”

Ann Boucher, Director of Client Services, Community Care Access Centre of Peel

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Increased confidence about information sharedPartner physicians reported improved confidence incommunications and accuracy of informationbecause of their direct relationship with their homecare case manager/CCC. They said that prior tothe partnership, they would receive home careinformation (if any) from a variety of sources, andbecause there was no relationship in place theywere not as “comfortable” with the informationthey received.

Some of the partnership teams indicated they meton a regular basis and this helped their relationshipand their work; other teams who did not meet asregularly were interested in pursuing this notion,although they were concerned about being able toschedule the time to conduct such meetings.

Significance of tools and guidelinesProvider partners recognized the importantcontribution of standardized tools and carepathways (including minimum data sets) to optimalprovision of care.

IT enhancementsCalgary site leaders felt the IT changes that tookplace over the course of the Project (whileadmittedly challenging) have advanced things therein a very meaningful way (for example, there havebeen significant time savings, as well as increasedstandardization43) and there is much anticipation ofthings to come. As Cheryl Grady, Program PlanningManager, Home Care, Calgary Health Region, putsit: “The possibilities of what you can do with theproper IT piece are phenomenal.”

In Ontario, the hope is that as changes in IT arefurther operationalized, benefits will accrue bothfor patients/clients and providers.

From a system perspectiveImplementing ITAlthough the IT systems were not implemented inthe timeframe as expected, and this was a sourceof frustration, many providers stated that better IThas the potential to facilitate collaboration withintheir partnerships and create greater efficiencies inservice delivery through more timelycommunication, once it is being used moreconsistently. See ‘More of the story: The Project ITexperience’ at the end of this benefit.

“It all boils down to communication… As our partnership progressed, we becamemore comfortable with one another andwere able to work more closely together.”

Jeanette Adlington, Case Manager, Community Care Access Centre of Peel

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Two-way dialogue is essentialReciprocal communication within a partnership isimportant if shared accountability is the goal. Bothpartners need to feel that what they have to saywill be heard and valued. When communication ispositive and effective, partners feel invested in thework at hand and take more responsibility forensuring that work is done to the best of theirrespective abilities.

Extra effort is needed at theoutset of a partnershipBecause of the added time needed up front toestablish good communication protocols andpatterns, partners’ overall work/case load may needto be adjusted to reflect this extra commitment.

At the outset of a partnership relationship, peopleneed to spend time considering and then agreeingon their care guidelines, communication frameworkand tools, and communication frequency (throughstructured meeting time). Partners need to shareand communicate about both clinical and processmatters. Mechanisms to share information withinthe team should be simple and should not createextra work.

IT transformation takes timeAs the ‘Project IT experience’ story that followsclearly shows, there is no simple solution toaccelerating IT implementation and adoption.There are many constantly shifting variables tocontend with -- from the immediate pressures ofhow individuals and offices will cope and respondto the proposed changes, to the overarchingpressure of having to ensure IT solutions align withregional or provincial initiatives and requirements.Providers need continual reassurance that a certainlevel of discomfort or trepidation is natural, but thatthis will reduce over time as IT solutions unfold andfamiliarity is increased. Providers need to keep theirsights on the long-term benefits that better IT canoffer.

“In the past, we have had case managersthrough home care, but we had so many that,frankly, I had never met any of them. Now Ican call Jeanette because I know that togetherwe can ensure our patient gets the right kindof care.”

Dr. June Kingston, Trillium Health Group,Ontario physician partner

Lessons Learned

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More of the story...The Project IT experience

Electronic health records and enhanced ITsystems are critical to the efficient functioningand ongoing evolution of an integrated healthcare system. The Project sought to enhancelocal IT systems to support the Project priorityareas. However, IT changes could not bedivorced from wider (regional or provincial)initiatives, which made implementationcomplex and challenging. Notwithstanding,Calgary has already reported significant gainsin efficiency, and although Ontario did not golive until November 2005, participants arepositive about the potential and will continueto evaluate the solution beyond the Project.

As discussed in many of the High Impact Benefits inthis report, the IT piece of the Project was animportant enabler for the main areas of focus(chronic disease management, case management,and partnership). Clearly, effective IT systems areessential for good communication and for effectiveteamwork. Among other things, IT can:

• Reduce workload by allowing for easy retrievaland sharing of important patient/client medicaldata by different health care professionals

• Increase the capacity for communication andcollaboration

• Reduce duplication • Reduce the potential for problems related to

illegibility• Increase the opportunity for management to

track patient/client outcomes and variances• Enable the consistent application of clinical

practice guidelines and algorithms.

"IT enhancements won't do our work for us, butthey will enable us to do our work better."

Bob Morton, former Executive Director,Community Care Access Centre of Peel

The challenge of implementing an IT system tosupport the ProjectHowever, one of the main challenges faced by theProject participants was how to implement ITsystems to support the Project that would alsointegrate into the bigger picture of regional or

provincial IT strategies either already underway or inthe planning phase. Contending with thischallenge made the Project’s IT journey longer thanwas originally anticipated. Project sites had to workwith IT consultants to understand the regional andprovincial strategies and work the Project’s ITsolution into those larger strategies. The goodnews is the expectation that the solutions that wereeventually identified and implemented will be moresustainable as a result. For those readersparticularly interested in the IT segment of theProject, the Project website contains a detailedoverview of this topic, including a review of theProject IT objectives, the challenges recognized atProject outset (including background surroundingthe state of IT at both sites and the eventual Projectdecisions made), and the unfolding of the ITexperience at both sites.

Certainly, from the onset of the Project, physicians,case managers/CCCs and representatives from bothCalgary and Ontario expressed their anticipation ofthe enhanced IT systems. That said, delays in ITimplementation were a source of understandablefrustration for Project participants. Ultimately, themain areas of concern for providers were slowerthan anticipated progress, levels of integration withexisting systems, the degree of functionality, andthe time required to learn and effectively use thenew systems.

Calgary site IT solutionHaving gone live with its IT solution in Spring 2005,the Calgary site is now working on enhancementsto the solution. MDS-HC (assessment software)and Soprano (chronic disease managementsoftware application) will be maintained by theRegion and adopted more broadly.

The interface of the Soprano to the physicianelectronic medical record is taking longer thananticipated, but there is commitment to continuingthe work to establish this link. Importantly, theevaluation data shows that Calgary providers havebeen successful in maintaining their partnershipsand patient/client clinical outcomes whileundergoing the implementation of the IT solution

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and making adjustments to the deployment ofhome care staff. Calgary CCCs also reportsignificant time savings as a result of ITenhancements.

Ontario site IT solutionThe Ontario site’s IT solution went live in November2005. While later than originally anticipated, thiswas a major accomplishment because of thedecision to host the application at SSHA (SmartSystems for Health Agency, the provincialorganization responsible for technologyinfrastructure) where the complexity and rigor ofprocess is escalated by the nature of a provincialmandate.

Typically, start up to completion of a go live processcan take six months to a year depending on thecomplexity of the solution and coordination effortsinvolved. We were successful in completing theuser requirements with key stakeholders, prototypereview with the physicians, an approved designdocument, SSHA project sponsor support, serverhosting environment and equipment from SSHA,high speed Internet access provided by SSHA, UserAcceptance Testing, and resolution of softwareproblems and enhancements needed before thego-live point.

For some physicians the solution, at this point intime, requires duplication of effort. We areitemizing and prioritizing potential enhancements,including such things as creating interfaces tominimize duplication, that can be completed beforethe Project concludes. Because the go-live date ofthe IT solution occurred after the completion of thedata collection by our evaluation team, we areconducting a mini-evaluation of the solution todate.

We hope to get some validation that will supportcontinued use of the application and will identifypriority enhancements. We will work to implementas many enhancements as possible in order todemonstrate responsiveness to the Projectparticipants and help to secure commitment tocontinued use by the Ontario site.

Evolution of the IT solutionAt the time of the final Project survey, providers inboth Ontario and Calgary expressed that whileincreased electronic connectivity has improved theircomputer skills, it has not necessarily (to date)influenced the care they provide. Ultimately, the ‘ITstory’ from our Project has had several main themesto emphasize:

• IT enhancements are, by necessity, incremental— the full articulation of their benefits is notimmediate, but must follow a (sometimespainful) learning curve.

• The Project’s IT plans and strategies evolvedover time, and changed from the original visionat the start of the Project – what we learnedwas that it is often only by trying to createsomething that you realize what you reallyneed or want.

• While the IT aspects of the Project wentdifferently than we had expected, there werevaluable lessons in what did happen and thedirections taken.

While IT can be a powerful tool, the bottomline is that it cannot enable change withouthaving trusting partnerships in place.

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“Case managers applytheir knowledge, theirexperience, and theirtalent as equal membersof the health care team.”

Marg McAlister, National Partnership Project Manager

HighImpactBenefit

Reinforces value of system-level case management

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Aligning case managers withfamily physicians, and expandingthe role of home care in chronicdisease management positionsphysicians and case managers tofully contribute their respectivecase management skills sopatients/clients receive the bestcare possible.

Over the past two decades the evidence on diseasemanagement and case management as two inter-related interventions has shown improvement incare, health outcomes and costs to the health caresystem.44

Case management at a systems level is a strategyor process undertaken by all health careprofessionals (and even used by patients/clientsthemselves) to maximize patient/client wellness andautonomy through advocacy, communication,education, identification of service resources, andservice facilitation.

The principle of case management is also regardedas integral to the home care system, and ‘casemanagers’ are the individuals who are primarilyresponsible for this activity within the home caresector. However, there has been confusion aroundthe definition and contribution of casemanagement within the home care context,45 andthe full potential of case managers is not alwaysrealized.

Mission critical functions of a home care casemanagerAt the outset of the National Partnership Project wefocused on trying to understand how the homecare case manager’s role would be impacted if twokey strategies were implemented – that is,partnership with a family physician and a chronicdisease management focus. In particular, throughthe work-sampling (Function Analysis) portion ofthe Project, it was possible to consider what the‘mission critical’ functions of a home care casemanager working within a partnership and diseasemanagement model would be. We were interestedin how case managers’ roles might change as aresult of building trusting partnerships withphysicians; and how redeployment of some casemanager activities might help better achieve those‘mission critical’ functions within a chronic diseasemanagement model.

Systems level case managementHowever, while we went into the Project trying togain an understanding of the home care casemanager in this new context (and we gainedvaluable insight in this regard), what we also (andperhaps even more significantly) learned about wascase management on a broader, systems level. Wediscovered that when physicians and home carecase managers work in a defined structure wherethey are partnered together, they reinforce oneanother’s case management functions. Casemanagement on a systems level ends up workingfar better than when these groups of professionalswork independently.

It became very clear that family physicians remainas patients’ most common point of first contact forprimary health care. But the reality is that doctorssimply cannot fulfill this role alone and they requiregood access to community based service – accessthat can be provided through partnership with ahome care case manager. Further, by clarifying thehome care case manager’s role, both members inthe partnership are better able to contribute theirown unique case management skills andknowledge to effectively achieve integrated andcollaborative care. Essentially, the attitude becomes‘I’ll assume responsibility for this, you do thatportion, and we’ll do this part together.’

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9PremiseCase management on a broader systems levelimproves outcomes

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We found that...• When physicians move from a lack of

familiarity with home care to seeing casemanagers as integral partners in providingoptimal patient/client care, traditional barriersbetween home care and family physicians areremoved and interaction is very positive.

• When physicians feel as if case management isa collaborative effort, and they understand therole that home care case managers can play inthat effort, they feel less frustration aboutdealing with a bureaucracy and betterappreciation for the limitations and options tobe considered through home care.

• Joint decision-making by home care/familyphysician partners leads to betterunderstanding and allocation of resources (forexample, faster and more appropriate referrals).

• The home care case manager’s role in achievingimproved clinical outcomes for patients/clientswith chronic disease is validated.

• Physicians feel less alone and more supportedin dealing with their patients; home care casemanagers experience a huge increase insatisfaction with their role and their sense ofcontribution.

• Patients/clients are satisfied to know they havea team addressing their needs and recognizethe home care case manager as an importantpart of that team.

Effective casemanagement is acollaborative strategy.

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Discipline driven case management

Managing patient/client care fromwithin separate health care silos

A complicated maze of servicesthat are challenging to access

Collaborative case management activities where eachdiscipline agrees to a care algorithm

Managing patient/client care as a team

A network of services navigated by experts

Our Experience

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From a patient/clientperspective Teams work By the time of the final Project survey, more thanseven in ten patients/clients said their Projectproviders worked as a team to link them with theright health care provider or service and 65% saidtheir providers worked as a team to give ongoingsupport (reasons for a slight decrease in this figureover the life of the Project are explored in our HighImpact Benefit on chronic disease management).

There was a significant increase over the course ofthe Project in the percentage of patients/clientswho felt their home care case manager was opento their questions and opinions on treatment andcare.46

The story around satisfaction rates related to actualhome care treatment and education is told in ourHigh Impact Benefit on patient/clientempowerment.

From a provider perspective Partnership leads to understanding Project physicians said the partnership theyestablished with a case management resource (i.e.,their case manager or CCC) provided them withbetter understanding and insight regarding the casemanager/CCC role.

Increased collaboration Provider partners reported an improvement in theircollaboration over the life of the Project, althoughthey also noted this was a gradual process andsomething that requires ongoing commitment. Allproviders agreed that it took time to build trust andthat team-building is an essential first-step towardany partnership effort.

Better use of core competenciesPhysicians expressed that by understanding the roleof home care case managers within the larger casemanagement context (that is, what services andassistance home care could provide), physicianswere better able to focus on their own corecompetencies; they also said that through thepartnership they felt supported in their efforts tooffer the best care possible for their patients.

Our Evidence

“In family medicine in Canada, there arenot enough family physicians. Quite simply,we cannot offer the kind of broad servicesand coordinated care that are necessarywithout some sort of connection to ateam.”

Dr. Adrian Gretton, Southwest Medical Centre,Alberta physician partner

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Role adaptationThe role of case managers/CCCs actually changedwithin each site through the course of the Projectas Function Analysis results were shared withparticipants.47 Case managers and CCCs took onthe unique role of bonding, bridging and linkingindividuals with chronic disease to the broader carecommunity. This, in turn, allowed physicianpartners to better focus on clinical care within theoffice setting as well as more effectively engage intheir piece of the broader ‘case management’function. See ‘More of the story: Refining andredefining roles within a partnership’ at the end ofthis benefit section.

From a system perspectiveFewer boundaries A team approach to care, where home care casemanagers have a distinct role to play, leads toservice delivery that is more integrated andcoordinated; home care involvement helpsminimize the boundaries between physician andcommunity care. For example, as mentioned in ourprevious High Impact Benefit on communicationand decision-making, Project physicians’ referrals ofnon-diabetic (i.e., non-Project) patients/clients tohome care increased over the life of the Project asphysicians’ awareness and understanding of homecare services grew.

“Family physicians’ offices have not alwaysunderstood the whole range and breadth ofwhat home care can do for them and theirclients. One of the wonderful things aboutthis Project was seeing the docs reallyenergized about this ‘new-found treasure’.They’re really enjoying it and so we’reenjoying it too.”

Cathy Hecimovich, Director of Client Services, Community Care Access Centre of Halton

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Clarifying the role of home carecase managers can benefiteveryoneWhile the Project set out to augment and clarify therole of the home care case manager, what welearned about was the value of the casemanagement activity of every professional on theteam. By contributing the case manager’s ability tobond, bridge and link to the family physician’spractice, and by establishing a system of sharedaccountability, we were able to leverage thecompetencies of both members of the partnership.

Figuring out roles in apartnership can be challenging,but ultimately rewarding Case managers/CCCs relayed that having undefinedroles initially within a team caused some frustration,but also provided them with the flexibility to utilizetheir competencies to determine where they best fitinto the team. As the Project progressed, theynoted that their roles became clearer to themselvesand others.

Investing in home care has longterm payoffsBetter understanding of home care by physiciansled to more overall (non-diabetic) patient referralsto home care, a positive corollary effect from theProject, but it is important to recognize that anincreased demand for service also has budgetimplications.

Lessons Learned

“The broader scope of care that you canget through the CCAC [home care] issomething beyond the capabilities of mostfamily doctors. ”

Dr. George Southey, Dorval Family Health Team,Ontario physician partner

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It was anticipated that through ongoingevaluation, provider participants would beable to re-evaluate their roles through theresults of the work sampling data. Calgaryused the information to explore a CCC rolethat required less direct care. Halton/Peeldeveloped a model that increased direct timewith patients/clients and the physicianpartnership.

Physicians expressed that they were able toclarify their own role vis-à-vis home care andthat they were better supported to focus ontheir own best skills and competencies so theirpatients could receive optimal care fromeveryone involved.

As noted in our story on the cornerstones ofpartnership in our High Impact Benefit on healthhuman resources, partnerships are evolutionaryrelationships where partners’ roles need to beregularly reviewed and refined. This Project toowas built on the understanding that continuousevaluation would contribute to ongoing decisionmaking and continuous program improvements,including role refinement.

Evolving roles within the partnershipAs the Project’s two key strategies were brought tolife, it became evident that within the casemanager/physician partnerships there wereopportunities to redefine certain aspects of certainroles.

In particular, insights gained from early FunctionAnalysis data led to changes in the way home carecase managers/CCCs saw their case managementrole. In both Calgary and Ontario, FunctionAnalysis results were used to inform participantsabout efficiencies in practice by reducing the extentof duplication, rework, hand-offs, and use ofpaper-based tools. Specific activities wereemployed at both sites to build team capacity andclarify and delineate roles and functions betweenand among the team.

The clarity in roles enabled a greater focus oncritical functions (specifically bonding, bridging andlinking individuals with chronic disease to thebroader care community) that have a direct impacton patient/client care and health outcomes, andless focus on areas that could be appropriatelytriaged to another member of the care team.

Both sites then used this information to adapt in adifferent way.

Evolution at the Calgary siteAs a result of the Project, Calgary has movedtowards a new model of case management thatreduces direct care offered by CCCs, increasescollaboration and navigation activities, and reducesfragmentation. Specifically, by reassigning certainchronic care activities such as wound care to othermembers of the care team, more time is availablefor CCCs to focus on health promotion, increasingpatient/client self-care capacity, and other bonding,bridging and linking functions (components of theCCCs’ role that were not occurring with desiredfrequency).

“Bringing appropriate care providers together andhaving them focus in a more coordinated fashionon targets like A1C levels increases the likelihoodthose targets will be met.”

Dr. John Maxted, Associate Executive Director, Health & Public Policy,

The College of Family Physicians of Canada, Member of Project Advisory Board

More of the story...Refining and redefining roles withina partnership

Evolution at the Ontario siteFor its part, the Ontario site has developed a modelthat reduces a case manager’s indirect patient/clientactivities and increases direct time withpatients/clients and the physician partnership.

It should be noted that role refinement for casemanagers/CCCs has also clearly involved roleenhancement and redefinition for other membersof the home care team such as float RNs and LPNs(in Calgary) and team assistants (in Ontario, wherestrategic efforts were made to re-engineerprocesses in reducing case manager administrativeactivities and improve communication betweencase managers and team assistants).

Impact on partnersFunction Analysis results gathered near the end ofthe Project showed that case manager/CCC timehad, indeed, been significantly and successfullyredirected and there was considerably moreemphasis on chronic disease management andcollaborative team practice, both best practiceswithin primary care.

Finally, not only were home care provider rolesredefined, but physicians in the Project notedduring final interviews that they had initiated somechanges to their patterns of practice as a result oftheir involvement with the Project. For example,Ontario physicians reported that with an increasedawareness and understanding of home careservices, they increased their referrals to home care.Having a designated case manager also streamlinedthe process for physicians to gather informationfrom and about home care. Physicians furtherexpressed that by knowing what home care couldand would do, they could focus on their own corecompetencies much better so that patients wereable to receive the best care possible.

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Case management is a collaborative client-driven strategy for the provision of qualityhealth and support services through theeffective and efficient use of resources inorder to support the client’s achievement of goals.

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“This Project isabout using scarce health careresources mosteffectively.”

Bob Morton, former Executive Director, Community Care Access Centre of Peel

HighImpactBenefit

Demonstrates potential for improved costmanagement

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Aligning case managers withfamily physicians, and expandingthe role of home care in chronicdisease management has thepotential to contribute to costmanagement within the health caresystem.

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Savings are anticipated as a result ofpartnerships

Research has shown that changing the way healthcare is approached and delivered can contribute tomore effective cost management of limited healthcare resources. It has been proven, for example,that:

• Applying the chronic care model improvespatient/client outcomes and reduces costs formany chronic conditions.48

• A team approach to patient/client care reduceshospitalization time and costs, improves serviceprovision, and enhances patient/clientsatisfaction, staff motivation and teaminnovation.49

• Case management interventions implementedin a collaborative practice model improve care,outcomes and costs for individuals andpopulations with diabetes.50

• Home care is more cost effective than theacute care sector.

• As patient/client data accumulates over time,the use of enhanced IT systems leads tofinancial savings from less staff time spentfinding, pulling, and filing charts and lessphysician time spent locating information.

The right care at the right timeThe Project did not undertake a formal study ofhow a partnership model for home care and familyphysicians, working within a chronic diseasemanagement framework, could impact health carecosts. What was anticipated was that by workingtogether as a team, each partner would be enabledto provide his/her best professional service moreefficiently (that is, the right care at the right time).

Similarly, we anticipated that proactive healthpromotion and illness prevention strategies wouldhelp to delay deterioration and/or reduce theincidence of acute exacerbations, which typicallyrequire more costly interventions.

Using IT systems as an enablerFinally, we hoped that new IT systems would serve as an enabler to the Project partners, andimproved communication would reduce tediousduplication. By ending voice mail madness andexcessive administration, the anticipation was thatproviders would have more time to focus on theircore competencies. We further hoped that betterIT systems would allow the team to accessinformation in a timely manner, which would letthem serve their patients/clients more effectively.The storage of information would also enable theteam to monitor a patient/client population andplan interventions specific to the group served.

The Project experience and findings were reviewedwith these expectations in mind, to see if therewere signs that cost management could potentiallybe positively impacted if the key strategies theProject employed were executed on a larger scale.

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We found that...• System barriers are minimized as partners work

together, understand each other’s context, andmove to joint decision-making about bestutilization of limited health care resources.

• Team-based care with shared accountability ismore effective and efficient. Physicians canconfidently delegate aspects of care to homecare case managers, thereby ensuring best carefor patients/clients.

• Using the right person for the rightintervention makes sense, is cost effective, andis professionally gratifying.

• By enhancing case management and improvingcommunication, the primary care/home careteam can detect and prevent both costly anddebilitating complications and reduce thefrequency of crisis situations.

• The administrative burden placed on healthcare professionals can be reduced and/orredirected, thereby ensuring best use of funds.

Home care and primarycare partnerships areeffective andrewarding.

From ToBy moving

Minimal use of electronic records anddata management

Copious amounts of informationrecorded in multiple files

A reactive approach to patient/clientcare

Excessive use of voice mail

Heavy administrative component

Increased use of IT to track patient/client information and clinicaloutcomes, both in terms of individual patients/clients and forpatient/client populations within a practice

A minimum data set that effectively captures that informationwhich the team of professionals believes is necessary to providecare

A proactive, disease management approach with an emphasison health promotion and earlier interventions, to prevent thenecessity of using more costly acute or episodic care andinstitutional services

Internet based communication that serves to improvedocumentation

Decreased time and expense related to paperwork

Our Experience

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From a patient/clientperspectiveTeams workMost Project patients/clients said they felt theirproviders worked as a team to ensure thepatient/client saw the right type of health careprovider and had ongoing support (more on thisfinding is discussed in our High Impact Benefit onchronic disease management in the community).

Reduced A1C levels The first two cohorts of Project patients/clients inCalgary experienced a statistically significantreduction in their A1C levels during the Projecttimeframe. In light of research that links A1C levelsand medical charges, this was a finding that wasexciting in terms of the cost savings potential itcould point to.51 For more on the A1C story seeour High Benefit Impact on quality care forpatients/clients.

From a provider perspectiveBetter resource usageFor their part, provider partners reportedanecdotally that they felt they were able to usescarce specialized health resources much moreefficiently.

Leveraging competenciesSynergies through collaboration produced moreefficient care, and leveraging the skills of eachmember of the health care team meant thatsolutions were enhanced, not rediscovered.

Better use of timeFunction Analysis results52 showed that casemanagers/CCCs experienced a reduction in paper-based activities by the end of the Project, alongwith a corresponding reduction in administrativetime.53

From a system perspectiveQuality care and efficiency through ITThe anticipation was that with further refinementof IT systems, better organization of healthinformation and its timely availability would resultin better service quality and a reduction induplication of care. The IT story is discussed ingreater detail in our High Impact Benefit oncommunication and decision-making.

Our Evidence

“It (the model) lets each member of thepartnership do what he/she does best,rather than spinning wheels on work that isnot within his/her particular area ofexpertise or skill set”

Dr. George Southey, Dorval Family Health Team,Ontario physician partner

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“The greatest benefit fora family physician ismore efficient use oftime. By meetingregularly with a casemanager you know andtrust, a family physiciancan be assured his/herpatients are getting theright care in an efficientmanner.”

Dr. June Kingston, Trillium Health Group Ontario physician partner

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New IT systems require timeand patienceThe effort to reduce duplication through enhancedIT is definitely worthwhile, but takes time; theremay, in fact, initially be more duplication as newsystems are established.

Need to commit to dataanalysis Having the ability to store patient/client healthinformation for population analysis is wonderful,but providers need to commit time and resources tobe able to review and reflect on this information sothat it truly can be useful on a larger scale.

Re-considering roles and dutiesalso requires time and patienceIt can take some time to figure out whoshould/could best be filling a certain role orfunction (particularly in relation to trying to re-directsome administrative tasks), and every partnershipwill figure out its own best solution, but the resultsin terms of efficiency and the better use ofeveryone’s professional skills are certainly wellworth the effort.

The bottom line: Providers need to look atthe ‘big picture gains’ when undertakingsystems changes – the reality is thattransformation can be challenging andfrustrating at times, and adaptations must bemade en route.

Lessons Learned

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“Part of the value of thisProject is that it servesas a demonstration forothers. It signals thatthey too can work inpartnership to providethe right care...”

Nancy Milroy-Swainson, Director of Primary and Continuing Healthcare Division,

Health Canada

Recommendations & Action Planning

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The National Partnership Project demonstrated thatprimary health care is enhanced through theinvolvement of home care, particularly forindividuals with a chronic disease. Partnershipsbetween physicians and home case managers werecreated, and where already existing, wereenhanced; the scope of home care was increasedto include proactive care for patients with chronicdisease and IT systems were implemented.

Home care case managers at the Project sites wereable to effectively support their physician partnersto ensure that patients with diabetes received casemanagement interventions to assess and reassesstheir needs according to clinical practice guidelinesand algorithms developed by the teams. Over 900clients benefited from the initiative and expressedincreasing levels of satisfaction over the life of theProject with this model of care.

CCCs, case managers and physicians reported highlevels of satisfaction with the case management,chronic disease management, and collaborationaspects of the Project. Most felt that Projectinterventions in these areas had a positive impacton patient/client care, interactions with other healthcare professionals, and improved their knowledge,skills and attitude in providing care to patients withdiabetes. Providers reported increased levels oftrust, communication and information sharing.

There was evidence of improved clinical indicators.In Calgary, where the model had been in placelonger, the decrease in A1C for patients wasstatistically significant – an achievement that is evenmore noteworthy as the Calgary site implementedtwo software systems during the implementationphase of the Project. In Ontario, improvements inA1C were noted but statistical significance was notachieved. Given Calgary’s experience, positivetrends achieved in Ontario do suggest that as themodel matures, the Ontario participants have thepotential to improve their A1C levels.

The partnership of family physician and home carecase manager resulted in increased referrals to thehome care program in Ontario. This was notidentified in Calgary as the model has beenoperational for a number of years. CCAC staff inOntario reported that the referrals by physiciansreflected an improvement in physicians'understanding of services that can support theirpatients. Both the case managers and physiciansexperienced enhanced collaboration and problemsolving. They reported an awareness of consciouslymaking choices for their patients with a betterunderstanding of limited resources and the broaderrange of services available.

RecommendationsThe Project sites have committed to continuing thepartnership and information technology solutionsadopted throughout the Project. Sustainablepartnerships between case managers and primarycare physicians will require changes to home careprograms. Home care programs will need tocontinue expanding their capacity to serve moreclients and their ability to serve a different mix ofclients with a range of needs. The Canadian HomeCare Association recommends that:

• Case management be regarded as an overallstrategy central to primary health care inCanada. To that end, the contribution of bothphysician and home care partners to thisstrategy should be considered a first priorityoption when planning health care services.There must also be a commitment to operatingwithin a clinical framework wherein the entirehealth care team takes responsibility for clinicaloutcomes.

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Conclusion &Recommendations

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• Chronic disease management be recognized asa community-based responsibility, whereinhome care can, and should, play an integralrole. Both resources and training are neededfor this expanded role.

• More resources and training be devoted to thedevelopment of teamwork and partnership thatachieves productive collaboration amongst theprimary health care team.

• Continued investment in and emphasis(including public education) on the vitalimportance of electronic health records andenhanced health IT systems occur. Progress inthese areas must proceed as rapidly as possible.

• The use of electronic forms and tools (includingalgorithms and minimum data sets) continuesto be a high-priority area for health providers.These tools are critically important as bestpractice guidelines that help to ensureconsistency and direction for managingpatient/client care, both on an individual andpopulation level.

The Canadian Home Care Association thanks youfor your interest in this report and the story it tellsof the National Partnership Project. As indicated atthe outset, the Project was a demonstrationinitiative and not research based, a design set outby Health Canada and the Primary Health CareTransition Fund. This report has sought to conveyhow Project participants (providers andpatients/clients alike) felt real enthusiasm abouttheir Project experiences. Our hope is that otherjurisdictions will reflect on what took place, usewhatever information and resources we can offer,and pursue similar initiatives designed especially fortheir own unique needs and circumstances.

Two key strategies for change

• Aligning home care case managers with family physiciansthrough formalized and structured partnership, thereby creating health teams uniquely equipped to provide optimalpatient/client care.

• Expanding the role of home care in chronic diseasemanagement to serve a broader scope of patients who wouldbenefit from earlier interventions in order to improve their self-management.

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Action PlanningAn introductory road map for building partnerships between homecare and family physicians within a chronic disease management model

For readers interested in pursuing models similar tothose in the Project, our ‘High Impact Benefits’ allcontain valuable lessons we learned en route.

Our participants also felt a very brief run-down ofsome of the ‘best advice’ they have to give arisingfrom their experiences in the Project could giveother jurisdictions a starting point for their ownjourneys. Here is that advice:

When building partnerships • Adapt the nature of the partnership

arrangement to suit the partners’ needs:recognizing the mission, values and priorities ofthe partner organizations is very important.

• The nature of partnership required to achieveproductive collaboration takes time, and itrequires the development of a trustingrelationship.

• In particular, take the time up front to agree onpartner roles, responsibilities, communicationmechanisms, etc. (and recognize that some ofthis work can be challenging).

• It can be very helpful to engage in team-building exercises at the outset and to focus onearly wins so partners can see the potential intheir new patterns; there needs to be awillingness to empower staff within partnerorganizations to take risks, and there needs tobe recognition that new approaches may needmodification over time.

• Consider how the partnership arrangementmay impact on workload and workflow issues,and how it may impact on the roles andrelationships of other members of the broaderteam (for example, administrative support).

• Consider how the partnership may impact onreimbursement issues for physicians.

• Consider how to build in time for partners’meetings – two-way dialogue is essential, andpartners need to communicate about bothclinical and process matters; however,mechanisms to share information do need tobe kept simple rather than creating extra work.

• Physician champions who will provideleadership and support are invaluable; similarly,having senior management commitment andenthusiasm within home care is essential.

Reorganizing home care case managers toalign/partner with family physician practicesmakes sense and can happen quite easilyand without huge costs.

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When working in a chronicdisease management model

• Partners need to understand and agree onwhich specific patient/client outcomes arebeing sought and how they will be measured.

• Using standardized tools and pathways canhelp everyone focus on the same thing andensure shared accountability; be prepared torefine and revise these tools as required.

• Listen and learn from your patients/clients interms of how to best assist them become moreactive participants in their own diseasemanagement.

• Partners should consider together how othercommunity health care service providers andprofessionals will interact and fit into thepartnership arrangement.

• Allot time and resources for training sopartners can have adequate knowledge andconfidence about working within a chronicdisease management model (including learningabout the use of standardized tools and clinicalguidelines).

When making changes to ITsystems

• Enhancements are incremental, and benefitsoften follow a challenging learning curve.

• What you end up with often differs from youroriginal vision.

• While IT can enable good care and goodcommunication, technological changes don’tchange people – having trusting relationshipsand strong communication is still the mostimportant starting point for collaborative careand a team approach.

• Health care providers need appropriate timeand training to make the transition to new ITsystems.

Video testimonials, tools,resources and quick facts areavailable atwww.cdnhomecare.ca

“I would encourage our colleagues in otherregions or provinces or across the countryto embark on something like the Project…”

Dr. Richard Musto, Executive Medical Director, Southeast Community Portfolio,

Calgary Health Region

"This [the Project] hasallowed us to be proactivein the care of not onlytraditional home careclients, but it has enabledus to look after clientsbefore they even get intothe traditional home carestream. So what we’rereally trying to do is to keeppeople healthier for alonger period of time."

Carol Slauenwhite, Primary Care Specialist, Calgary Health Region

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Appendix A

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AcknowledgementsThe Canadian Home Care Association (CHCA) is anational, not-for-profit membership organizationrepresenting over 600 organizations and individualsfrom publicly funded home care programs, not-forprofit and proprietary service agencies, consumers,researchers, educators and others with an interestin home care. Through ongoing dialogue,publications, and position papers the CHCA acts asa united voice and access point for information andknowledge about home care across Canada.

The National Partnership Project would not havebeen possible without the cooperation of countlessindividuals who contributed their time andresources to this exciting initiative. On behalf ofthe CHCA Board of Directors, we would like toexpress our appreciation to all these individuals andorganizations for their input and support.

Project Sponsor(CHCA)

Nadine Henningsen Executive Director, CHCA

Marg McAlisterProject Manager

Lisa WaltersDevelopment of Project Report

Project Site Leads

Carol Slauenwhite, CalgaryLynne McTaggart, HaltonLucia Cheung, Peel

Alberta (Calgary Health Region)Community Care Coordinators

Laura Brule Susan EvansDonna Kerr Dianna KillickRoyalene Reed Dawn RudigerVirgina Smale Donna Smith

Alberta (Calgary Health Region)Physician Partners

Dr. George Barr Dr. June BergmanDr. Chris Bockmuehl Dr. John CarterDr. Oliver David Dr. Ted FindlayDr. Connie Ellis Dr. Perry GlimpelDr. Adrian Gretton Dr. Barry HardinDr. Kenneth Maclean Dr. John MahDr. Marie Patton Dr. Elisabeth RetzerDr. Serge Soolsma

Alberta (Calgary Health Region)

Linda Andrusiw, Area ManagerCheryl Grady, Program Project ManagerLinda MacDonald, Area ManagerPat Reader, CDM Information ManagerDonna Piche, Area Manager Dr. Rosario Talavera, Manager Information SystemsWanda Moore, Primary CareAnita Lal, Primary Care

Alberta (Calgary Health Region)Senior Leadership

Sandra Delon, Director, Chronic Disease ManagementBrenda Huband, Vice President, Southeast CommunityPortfolioBarbara Korabek, past Director, Home CareDr. Richard Musto, Executive Medical Director,Southeast Community PortfolioJanice Stewart, Acting Director for Home CareJoan deBruyn, Director, Home Care

Ontario Case Managers

Halton Community Care Access CentrePat Colpitts Karen McGilvray

Peel Community Care Access CentreRuth Armishaw Jeanette AdlingtonEvadne Henry Denyse JohnsonKaren Kowal Janet Tamburri

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Ontario Physician Partners

Dorval Family Health NetworkDr. Corinne Breen Dr. Margaret H. FoundDr. Alexander Ginty Dr. Nancy KuDr. Jonathan Lapp Dr. George Southey (Lead)

Applehills Medical AssociatesDr. Alex Borgiel Dr. Ted NemteanDr. James Miller Dr. Alaisdair MackintoshDr. Michael Gitterman Dr. Don Collins-Williams (Lead)

Trillium Family Health GroupDr. Victoria Chen Dr. Cheryl HewittDr. June Kingston (Lead) Dr. Rhonda Wilansky

Ontario Senior Leadership

Halton Community Care Access CentreSandra Henderson, Executive Director Cathy Hecimovich, Director Client ServicesCarmen Harvey, Director Corporate Services

Peel Community Care Access CentreRobert Morton, past Executive Director Ann Boucher, Executive DirectorJoan MacIntosh, Director Client ServicesClara Secnik, Director Corporate Services

Ontario

Halton Community Care Access CentreBrad Thornborrow, Information Systems Manager

Peel Community Care Access CentreLiz Churchill, Manager of Business SystemsIgor Orel, Manager, Information Technology

Project Partners

Karen Parent, Workflow Integrity NetworkMichele Jordan, IBM Business Consulting ServicesBeena Tharakan, IBM Business Consulting Services

IT Contractors

Dennis Rankin, IT ConsultantFrank Scarpino, Solution AlternativesWendy Landree, Sierra Systems

Project Advisory Board

Dr. Murray Nixon, Advisory Board Chair, past PresidentCanadian Home Care Association

Dr. Jim Armstrong, CEO, Ontario Association ofCommunity Care Access Centres

Dr. Jeanne Besner, Director of Research Initiatives inNursing and Health, Calgary Health Region

Jan Kasperski, Executive Director & CEO, OntarioCollege of Family Physicians

Viven Lai, Senior Manager, Senior Policy Advisor, Alberta Health and Wellness

Dr. John Maxted, Associate Executive Director, Health &Public Policy, The College of Family Physicians of Canada

Vida Vaitonis, Director, Home and Community SupportBranch, Ontario Ministry of Health and Long Term Care

Dr. Peter Coyte, Professor & CHSRF/CIHR HealthServices Chair, University of Toronto

Dr. June Bergman, Assistant Professor of FamilyMedicine, University of Calgary

Simone Comeau-Geddry, President, CambridgeConsultants

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Objectives & Logic Model

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Appendix BObjectivesThe Project performance was measured against these objectives.

National Partnership Project Objectives1 Increased access to case management for PHC and home care

2 Increased collaboration between patients/clients and providers

3 Improvement in personal health practices (health promotion,disease prevention, self-care) and health status

4 Increased client satisfaction

5 Reduction in avoidable/ unnecessary use of institutionalservices

6 Development of provider partnerships

7 Enhanced collaborative care among Project providers

8 Increased use of tools and evidence-based clinical guidelinesfor chronic disease management by Project providers

9 Increased electronic connectivity amongst providers

10 Increased information sharing amongst providers

11 Improved coordination of service

12 Increased provider satisfaction

13 Improved efficiency of service delivery

14 Improved ability to evaluate health outcomes, use of healthcare services, and patient/client and provider satisfaction

15 Increased public and stakeholder awareness of change in PHCservices and PHC renewal

Client Objectives

Provider Objectives

Public Objectives

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To enhance and augment primary health care providercollaboration through a strengthened role of home care case

management for clients/patients with chronic diseases

PHC services delivered at 2 sites inOntario and Alberta

Provision of“traditional”

PHCservices

Strengthenedcase

management

Collaborationbetween PHC

and home care

EnhancedInformationTechnology

Collectionand sharingof program

data

Publicrelations andknowledgeexchange

GeneralPublic

• Increasedawareness ofchange inPHC services

• Increasedawareness ofPHC renewal

• Betterunderstandingof PHCservices

• Adoption by otherjurisdictions

Measurement andMonitoring

Marketing andCommunications

Patients of PHC practiceswith specific chronic

conditions

Service providers (family physicians, case managers and others)

• Increased access to homecare case management byPHC patients/clients

• Increased patient/clientsatisfaction

• Increased collaborationbetween patients/clients and providers

• Improvement in personalhealth practices (healthpromotion, diseaseprevention, self- care)

• Reduction in avoidable/unnecessary institutionaliza-tion

• Increased collaborative care among providers• Increased provider partnerships• Increased use of chronic disease management

tools and evidence-based guidelines byinterdisciplinary teams

• Increased electronic connectivity• Increased information sharing• Improved coordination of services• Increased provider satisfaction• Improved efficiency of service delivery• Improved ability to evaluate health outcomes,

service use and satisfaction levels

• Improved health outcomes• Increased involvement in

health promotion anddisease management

• Sustained provider partnerships• Better integration of PHC and home care

services

Mandate

ProgramComponents

Activities

TargetPopulation

Short - TermOutcomes

Long - TermOutcomes

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Appendix CEndnotes1 As revealed in recent surveys by the National Primary Health Care Awareness Strategy, many Canadians areunsure what ‘primary health care’ means. The Strategy itself is designed to address this confusion. In itsown ‘fact sheet on primary health care’, the Strategy acknowledges that primary health care defies anysingle definition, but says it essentially refers to the basic, everyday health care accessed by Canadians. TheStrategy describes that primary health care is built on several key pillars: healthy living (including a focus onprevention and self-care), a team approach to patient/client care, a ‘24/7’ access to the right services whenneeded, and improved information sharing between health providers and expanded access to healthinformation by Canadians (through the use of tools and electronic health records and systems). TheNational Partnership Project is itself (as befits a Primary Health Care Transition Fund project) built on many ofthese same pillars. For more information on the Primary Health Care Awareness Strategy, please seewww.phc-ssp.ca.

2 We think it is significant to note here that in its second annual report on the overall status of Canadianhealth care (released February 2006), the Health Council of Canada cited primary care and home care as twoof five priority areas that require immediate attention to ensure better access to quality health care forCanadians. Interestingly, the report also focused on a great many other recommendations that align withthe work of the National Partnership Project, for example: • The need for faster implementation of interprofessional primary health care teams.• The need for greater use of electronic health records and technologies.• The importance of enabling health care professionals to practice to the best of their potential for the

best use of skill sets.• Expanding the range of home care services to assist people with chronic conditions.• Taking a team approach to chronic disease management, using standardized tools.For further information on the Health Council report, please see www.healthcouncilcanada.ca.

3 The full “Final Evaluation Report” for the Project, prepared by IBM Business Consulting Services, is alengthy analysis of the Project work and is available electronically upon request.

4 The Project was funded as a contribution agreement between CHCA and Health Canada, specificallyintended to advance primary health care initiatives. The focus was on working in a live environment asopposed to a more carefully controlled research setting. Our one main clinical indicator was looking atpatient/client A1C levels over the life of the Project.

5 Interdisciplinary diabetic management programs are a particularly relevant example of such an approach, inlight of the National Partnership Project’s focus on diabetes.

6 For the purpose of this report, ‘providers’ refers to the home care case managers and physicians who werethe health care providers central to the Project. Other health care providers will be specifically referenced bytheir discipline.

7 Clarke, J et al: Evaluation of a Comprehensive Diabetes Disease Management Program: Progress in theStruggle for Sustained Behavior Change. Disease Management. Volume 5, No. 2, 2002.

8 A document or file having a preset format, used as a starting point for a particular application so that theformat does not have to be recreated each time it is used.

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9 Diabetes is one of the few disease pathologies where the literature does exist to support the hypothesisthat case management as an intervention, in and of itself, can make an absolute change in the outcomes ofpatients/clients with the condition. Norris et al (2002): The Effectiveness of Disease and Case Managementfor People with Diabetes – A Systematic Review; The California Med-Cal Type 2 Diabetes Study, January2004.

10 The A1C test (haemoglobin A1C test, glycosylated haemoglobin A1C test, glycohaemoglobin A1C test, orA1C test) is a lab test that reveals average blood glucose over a period of two to three months. Specifically,it measures the number of glucose molecules attached to haemoglobin, a substance in red blood cells.

11 Ryan, EA, Todd, KR, Estey, A, Cook, B, Pick, M: Diabetes Education Evaluation: A Prospective OutcomeStudy. Canadian Journal of Diabetes. Volume 26, June 2002, pp. 113-119.

12 Norris, S et al: The Effectiveness of Disease and Case Management for People with Diabetes: A SystematicReview. American Journal of Preventive Medicine. Volume 22(4S), 2002, p. 15.

13 Recognizing that each time the case manager Function Analysis (FA) process was undertaken it could onlycapture one week in time, the FA study was useful to the Project home care programs in considering theredeployment of case manager/CCC activities; however, data cannot be relied on as conclusive statisticalinformation regarding how much time a case manager/CCC engages in certain activities (given there wereno work load indices). Nevertheless, the overall trends and patterns noted through the FA were, from theProject perspective, both significant and suggestive.

14 Statistics Canada Health Reports, Vol. 9, No. 3, Winter 1997.

15 Patient/client surveys were done solely with patients in Ontario, because Calgary patients/clients hadalready been involved in a partnership model of care previous to the National Partnership Project (HealthInnovation Fund Project #307), so would not necessarily perceive any dramatic changes in the way their carewas delivered. When those Calgary patients/clients were surveyed as part of the preceding Calgary initiative,results were very much in keeping with Partnership Project results for Ontario patients/clients.

16 In a January 2006 article in Clinical Diabetes (Volume 24, 2006, pp. 6-8.), researcher Dr. A. M. Delamatersays: “As the ‘gold standard’ measure of diabetes control, [the A1C] test provides important feedback tohealth care professionals and patients. It follows that patients’ understanding of this test and its implicationsfor long-term health risk is essential.” Delemater comments that relatively few studies have examineddiabetic patients’ knowledge and understanding of A1C testing. Delamater’s own study concludes: “Mostpatients do not understand the test and are not aware of their recent A1C results. Clinicians have theopportunity to use the A1C test as part of the clinical encounter to engage their patients, discuss theirglycemic goals, and work collaboratively with them to improve diabetes self-management.”

17 Beckley, ET: Knowing A1C Goal Begets Better Control. DOC News. Volume 2, No. 9, September 1, 2005,p. 7.

18 [http://www.diabetes.ca/cpg2003/chapters.aspx; Gilmer TP, O’Conner PJ, Manning WG, Rush WA: The costto health plans of poor glycemic control. Diabetes Care 20:1847–1853, 1997

19 Statistics Canada Health Reports. Volume. 9, No. 3, Winter 1997.

20 See Endnote 15.

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21 Wagner, E et al: “Improving Chronic Illness Care: Translating Evidence Into Action; Interventions thatencourage people to acquire self-management skills are essential in chronic illness care.” The People-To-People Health Foundation, Inc., Health Affairs, 2001.

22 From: http://www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/index_e.html

23 Comments made by Alberta-based Capital Health President and CEO Sheila Weatherill on February 15,2006, the opening day of a major conference on primary health care in Edmonton. Seewww.capitalhealth.ca

24 Canadian Institute for Health Information and Statistics Canada, Health Care In Canada 2005, p. 78.

25 See Endnote 13.

26 Powell, Suzanne K. Advanced Case Management – Outcomes and Beyond, p. 3.

27 National Academy of Social Insurance, “Medicare in the 21st Century: Building a Better Chronic CareSystem,” January 2003.

28 http://www.chronicdiseaseprevention.ca/content/case_for_change/case_for_change.asp

29 Gilmer TP, O’Conner PJ, Manning WG, Rush WA: The cost to health plans of poor glycemic control.Diabetes Care. Volume 20, 1997, pp. 1847–1853 and Wagner EH, Sandhu N, Newton KM, McCulloch DK,Ramsey SD, Grothaus LC: Effect of improved glycemic control on health care costs and utilization. JAMA.Volume 285, 2001, pp.182–189.

30 See Endnote 15.

31 For example, in Calgary, providers from other service disciplines were considered to be ad-hoc members ofthe partnership team and not fully integrated; furthermore, it was CCCs who did the liaising and physiciansrarely interacted with these other providers (and physicians actually indicated that they preferred having oneline of communication). In Ontario, both physicians and case managers noted that the Diabetic EducationCentre was not fully integrated with the partnership team. Case managers expressed the need to have theCentre and other providers better integrated with the team as the partnership model evolves. At both sites,time spent educating service providers at the early stages of Project implementation was significant, but itdid yield very positive results.

32 In Calgary, the Living Well with a Chronic Condition Program is integral to chronic disease management.Living Well Centres offer community-based exercise programs, disease education and self-managementclasses to enhance the capacity of individuals with chronic conditions to maintain or improve their quality oflife and manage their chronic disease. The facility infrastructure for this program is achieved by workingtogether with a variety of community groups. In both Alberta and Ontario, Diabetic Education Centres alsoplay a highly important role in diabetes management.

33 Ontario site results were not as resoundingly positive as Calgary, but this is understandable given therecent introduction of the tools and the fact that IT implementation was slower than originally anticipated.

34 The term ‘best practices’ is considered to be state-of-the-art medicine delivered in the most efficient andeffective manner.

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35 While the Project timeframe was too short to demonstrate this — for example, the Ontario patient/clientsurvey revealed that no Project patients were hospitalized for a reason related to their diabetes over the lifeof the Project — many other health program evaluations have cited reductions in hospital admissions andEmergency Department usage as a result of improved coordination and access to community-based services.See, for example, a study where a case management approach has been piloted with success in CastlefieldsHealth Centre in Runcorn, Cheshire (UK) - www.hda-online.org.uk/hdt/1101/local.html; and a 1997evaluation of the ‘Comprehensive Home Option of Integrated Care for the Elderly (CHOICE)’ in Edmonton –referenced in the Toronto District Health Council’s Coordinated, Accessible Community Health care for Eldersin Toronto: The CACHET Model. December 2004.

36 Hurst, K., Ford, J., Gleeson, C., Evaluating self-managed community teams. Journal of Management inMedicine. 2002, Vol 16(6), 463-483).]

37 Wagner, E et al.: Improving Chronic Illness Care: Translating Evidence Into Action; Interventions thatencourage people to acquire self-management skills are essential in chronic illness care. The People-To-People Health Foundation, Inc. Health Affairs. 2001.

38 Wagner, E et al.: Improving Chronic Illness Care: Translating Evidence Into Action; Interventions thatencourage people to acquire self-management skills are essential in chronic illness care. The People-To-People Health Foundation, Inc. Health Affairs. 2001.

39 For example, the establishment of a centralized, computerized database system that improves transfer ofinformation among all members of a team has been shown to improve the efficiency of diabetic health care.Canadian Diabetic Association Clinical Practice Guidelines. 2003.

40 See Endnote 15.

41 See Endnote 13.

42 This was a particularly positive trend in Calgary given the known and established relationships already inplace at baseline. In Ontario (where no previous partnerships had existed) case manager time withphysicians increased significantly at the outset of the Project (when the relationships were being established),then decreased somewhat in Time 2 (when some case managers were spending more time with thephysician’s office nurse, as different modes of partnership communication evolved).

43 For example, the computer-based RAI-HC tool (Resident Assessment System for Home Care) is now in use.

44 Norris et al, op. cit.

45 The Canadian Home Care Association held an invitational round table on this subject in March 2005 andlooked at the core principles, key elements, competencies, and outcomes of case management, as well asrecommendations to support effective case management. For a copy of the report from this round table,see: http://www.cdnhomecare.ca/reports_position.php.

46 See Endnote 15.

47 See Endnote 13.

48 “How the Chronic Care Model Has Been Operationalized in the Calgary Health Region”. Presentation byDr. Sandra Delon and Dr. Peter Sargious. Action Centre 2004.

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49 Borrill et al.: The Effectiveness of Health Care Teams In the National Health Service, 2000.

50 Norris et al, op. cit.

51 For example, a US historical cohort study found that a sustained reduction in A1C levels among adultdiabetic patients is associated with significant cost savings within 1 to 2 years of improvement. See Wagner,Sandhu et al, op. cit.

52 See Endnote 13.

53 The Calgary site actually showed an increase in administration time, but this was attributable to newcommunication methods employed by CCCs with their clients, and to adjustments to the new Sopranosystem, and the anticipation was that administration time would quickly reduce.