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South East Community Health Centres (CHCs) Chronic Disease Prevention & Management Network: An Integrated Approach to CDPM Carrie Salsbury, Program Director.

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Presentation on theme: "South East Community Health Centres (CHCs) Chronic Disease Prevention & Management Network: An Integrated Approach to CDPM Carrie Salsbury, Program Director."— Presentation transcript:

1 South East Community Health Centres (CHCs) Chronic Disease Prevention & Management Network: An Integrated Approach to CDPM Carrie Salsbury, Program Director Gateway Community Health Centre on behalf of SE CHC CDMP Network

2 SE CHC CDPM Network Country Roads CHC Gateway CHC Kingston CHC Merrickville CHC Susan Turnbull Carrie Salsbury Mike Bell (Chair) Ray Elgersma

3 Ministry Messages –growing prevalence and burden of chronic illness in our population –CDPM that is based on quality improvement principles, teams and clinical practice guidelines is supported –Strategies that demonstrate improved care and health outcomes for population with CD –Acknowledgement of CHC success with team & guidelines-based care

4 LHIN Messages –Data confirms population is aging, chronic disease is increasing –Significant health care capacity and cost/sustainability concern –LHIN wants change that promotes improved access to integrated approaches, is team-based, promotes measureable health outcomes & contains system costs –Priority areas include primary care systems, ehealth tools and connectivity, regional program continuums –Focus from Ministry is diabetes as first round

5 SE CHCs CDPM Network Purpose 2008-10 To Establish: Collaborative partnerships among CHCs with a focus on Increasing Service Quality and Evidence Based Practice Common CDPM indicator framework Collaborative Partnership CDSMP – Living Well with Chronic Conditions Stroke Prevention- improve processes to recognize and address common risk factors in primary health care. Increase uptake of HP practice by PHC providers

6 Long-Term Outcomes Reduced burden of chronic disease for clients & the health care system Reduced complications, preventable ER & specialist visits Improved quality of life for clients with chronic conditions

7

8 Network Areas of Focus 1.Self Management 2.Stroke Prevention Strategy 3.Indicator Development

9 1. SELF MANAGEMENT 1. SELF MANAGEMENT Living Well… With Chronic Conditions A SE CHCs Chronic Disease Self- Management Collaborative Program

10 OBJECTIVES Increase number of individuals with chronic illness receiving training in self management skills Increase number of individuals trained to deliver the Stanford SM Program Establish structure and processes to coordinate and maximize existing resources Establish regional plan for CDSMP

11 CDPM Achievements Self Management Network includes 16 organizations (CHCs FHTs & CSS 10 Master Trainers 29 Staff Leaders 17 Lay Leaders 250 participants (CHC only) 12 sessions completed for 2009/10 (CHC only) Creation of common data base for group evaluation

12 Where are we going …. Continue to educate, develop common marketing strategies to recruit participants Strengthen relationships with non CHC partners and create support network for Self Management leaders Develop & maintain a regional training schedule Investigate the potential for a regional license Investigate development of a regional website Evaluation – beyond self efficacy to include: healthy behaviour, health status and health utilization data

13 2. STROKE PREVENTION Project Goals: To increase awareness of risk factors of stroke To increase the uptake of health promotion concepts by primary health care teams To improve outcomes / reduce risk for clients by identifying risk, providing education & referral to health promotion and community prevention resources

14 Evaluation Methods Review and analyze project documents – proposal, progress reports, group feedback forms Review and analyze evaluation tools and indicators Semi-structured interviews with health promotion champions, providers and clients (21 total) –Pre and post provider surveys –Pre and post client surveys –Project intervention chart summaries

15 Achievements Primary Prevention Common risk assessment screening tool for stroke Provider survey Motivational interviewing training for over 90 practitioners Client education tool kit Developed clinical pathways for primary and secondary prevention

16 What did the project achieve? Uniqueness means distinctive strengths and challenges across sites No easy roll up of results and numbers Limitations of evaluation tools Highlight common results across sites in three areas: for providers, for clients, for CHCs

17 % of Men over age 40 with a BP measurement in a 24 month period Timeframe: April 1 2008 to March 31 2010 NumDenYTD GCHC859104183% MDCHSC818105278% CRCHC72396975% KCHC35644181% Timeframe: Oct 1 2007 to Sept 30 2009 NumDenYTD GCHC758110469% MDCHSC741113166% CRCHC567106353% KCHC32491835% Numerator: Primary care male clients, with an active status, over 40 years of age who had a BP measurement recorded in a clinical note using Purkinje. Denominator: Primary care male clients, with an active status, over 40 years of age. Calculation: Numerator divided by denominator times 100.

18 Indicator: % of Woman over age 50 with a BP measurement in a 24 month period Timeframe: April 1 2008 to March 31 2010 NumDenYTD GCHC75382791% MDHSC78793684% CRCHC67785379% KCHC33939985% Timeframe: Oct 1 2007 to Sept 30 2009 NumDenYTD GCHC66792272% MDCHSC739106969% CRCHC56396259% KCHC28970541% Numerator: Primary care female clients, with an active status, over 50 years of age who had a BP measurement recorded in a clinical note using Purkinje. Denominator: Primary care female clients, with an active status, over 50 years of age. Calculation: Numerator divided by denominator times 100.

19 % of Men over age 40 with a lipid profile in a 24 month period Timeframe: April 1 2008 to March 31 2010 NumDenYTD GCHC622104160% MDHSC715105268% CRCHC60096962% KCHC22844152% Timeframe: Oct 1 2007 to Sept 30 2009 NumDenYTD GCHC564110451% MDCHSC608113154% CRCHC413106339% KCHC15891817% Numerator: Primary care male clients, with an active status, over 40 years of age who had a lipid profile measured and recorded in a clinical note using Purkinje. Denominator: Primary care male clients, with an active status, over 40 years of age. Calculation: Numerator divided by denominator times 100.

20 Timeframe: April 1 2008 to March 31 2010 NumDenYTD GCHC52882764% MDHSC65493670% CRCHC53785363% KCHC23839960% Timeframe: Oct 1 2007 to Sept 30 2009 NumDenYTD GCHC47592252% MDCHSC590106955% CRCHC38796240% KCHC15770522% % of Woman over age 50 with a lipid profile in a 24 mth period Numerator: Female clients, with an active status, over 50 years of age who had a lipid profile measured and recorded in a clinical note using Purkinje. Denominator: Female clients, with an active status, over 50 years of age. Calculation: Numerator divided by denominator times 100.

21 Timeframe: April 1 2008 to March 31 2010 NumDenYTD GCHC1369299146% MDHSC1551349144% CRCHC7402,76727% KCHC477215522% Timeframe: Oct 1 2007 to Sept 30 2009 NumDenYTD GCHC2458294683% MDCHSC3410395986% CRCHC965275235% KCHC432287315% Clients over age 18 with obesity screening in 24 month period Numerator: Primary care Clients, with an active status, over 18 years of age who had obesity screening done and recorded in a clinical note using Purkinje. Denominator: Primary care clients, with an active status, over 18 years of age. Calculation: Numerator divided by denominator times 100.

22 Results for providers Increased awareness of community resources

23 Results for providers Increased referrals to CHC programs or community resources

24 Results for CHCs The project intended to touch: Interdisciplinary primary health care teams - increased use of health promotion concepts Clients – better outcomes and reduced risk CHCs/Organizations – new and more effective ways (systems, practices, norms) to do health promotion that will continue after the project

25 Results for CHCs Mixed impact on ongoing health promotion practices from high to low on a continuum Highest ongoing impact in CHCs who began with a plan to integrate project activities into ongoing work and who used both individual and group approaches Lowest ongoing impact in CHCs who used a group approach only and did not effectively link individual clients with primary care providers

26 3. INDICATOR DEVELOPMENT Varying approaches to evidence based practices in an interdisciplinary model that involves: individual and group sessions community capacity building broad based prevention strategies

27 Quality Improvement in Primary Health Care Service Delivery PDSA Cycle: model assists primary health care teams to: think about a problem for change design and test smaller focused changes adopt changes that work into practice on a larger scale move on to the next problem Helps teams to think and work together on problem solving, setting goals, managing emotions/interactions

28 SE CHCs Common CDPM Framework – Diabetes Continuum Improved clinical, functional and population outcomes Activated communities & prepared, proactive community partners Prepared, proactive, practice teams Adapted from MOHLTC Ontarios CDPM Framework, Nov. 2006 LHIN think Tank CDPM Supportive Environments Affordable housing Food security Affordable recreation Community Action Exercise programs Food security/good food box REACH Lay Lead CD SMP Healthy Public Policy Anti-smoking legislation Income security, affordable housing, employment protection Health System (Health Care Organizations) Delivery system Design Interdisciplinary teams Diabetes clinic Planned appts & quarterly testing/goal setting Diabetes education program Referrals to DEP, CDSMP, exercise programs, with monitoring & follow-up Provider Decision Support Current CPG formally embedded in daily practice Key indicators reports (CDA CPG) Alerts & reminders in Purkinje development CPOE, ECR, paper when necessary Information Systems Patient registry Recall/reminders Info access to all team members Alerts & reminders in Purkinje ECR, eLabs, paper when necessary Community Personal Skills & Self-Management Support Information & education with physician Information & education with RN/NP/RD in clinic Diabetes Education Stanford CD SMP Informed, activated, Individuals & families Productive interactions and relationships

29 SEISUG – South East Information User Group support achievements of SE CDPM Network Developed a standardized evaluation tool to measure outcomes of current CDPM initiatives queries using the Hummingbird BI application tool extract results directly from the Purkinje database

30 % of primary care clients with the following chronic diseases

31 % of active diabetes clients Numerator: # of active primary care clients with diabetes between age range Denominator: Total # of primary care clients at CHC Calculation: = # of diabetic clients / Total # of primary care clients*100 Inclusion Criteria: diabetic clients between age 18 and 75 with an active status and are registered to a physician or a nurse practitioner. Exclusion Criteria: Does not include clients registered to a personal development group or a community initiative. As of September 30, 2009 CHCNumDenYTD GCHC24737137% MDCHSC22944815% CRCHC26435148% KCHC22536986% As of March 31 2010 CHCNumDenYTD GCHC24537667% MDHSC24346075% CRCHC27635338% KCHC22737586% SE CHC Average: 6.5%

32 Numerator: # of active diabetic clients with an HbA1C test less than or equal to 7 Denominator: Total diabetic clients who have had an Hb1C test in past 6 months Calculation: = active diabetic clients with HbA1C test in past 6 months and a result <=7*100 Total active diabetic clients who have had a HbA1C test Inclusion Criteria: between 18 and 75 with an active status and are registered to a physician or a nurse practitioner. The result code description contains HbA1C and the result must equal or be less than 7. Exclusion Criteria: does not include clients solely registered to a personal development group or CI. % of DM clients with HbA1C result less than 7 April 1 2009 to March 31 2010 NumDenYTD GCHC12421358% MDHSC19725178% CRCHC15121770% KCHC7414850% April 1 2009 to September 30 2009 NumDenYTD GCHC9218450% MDCHSC9915265% CRCHC14019771% KCHC4410243%

33 % of DM clients with a self-management goal in past year Numerator: # of diabetic clients with a self-management goal Denominator:# of active primary care clients with diabetes between 18 and 75 Calculation: = # of diabetic clients with a self management goal *100 total # of diabetic clients Inclusion Criteria: between 18 and 75 with an active status and are registered to a physician or a nurse practitioner. Exclusion Criteria: does not include group clients. Limitations/ Data Quality Issues: Self-management is a recent concept integrated into CHC's. DMC's have struggled with where to place this information in the client chart to ensure that results can be reported, which has taken some time. April 1 2009 to March 31 2010 NumDenYTD GCHC4124517% MDHSC62512% CRCHC11927643% KCHC02470% October 1 2008 to September 30 2009 NumDenYTD GCHC132475% MDCHSC32291% CRCHC10426439% KCHC02250%

34 % of DM clients with LDL < 2.0 Numerator: # of active diabetic clients with LDL less than 2 Denominator: Total active primary care diabetes clients between age range with LDL result Calculation: = # of DM clients with LDL result <2 * 100 Total active diabetic clients with a LDL test completed within timeframe Inclusion Criteria: diabetes clients between 18 and 75 with an active status and are registered to a physician or a nurse practitioner with at least once LDL result. Exclusion Criteria: does not include clients solely registered to a personal development group or CI. April 1 2009 to September 30 2009 NumDenYTD GCHC7114948% MDCHSC7115147% CRCHC6013245% KCHC238427% April 1 2009 to March 31 2010 NumDenYTD GCHC7015445% MDHSC9919750% CRCHC10121647% KCHC3713927%

35 Achievements Quality Improvement Common indicators developed for diabetes and hypertension Developing common data definitions, data queries to extract information from EMR to support analysis and quality improvement Developing capacity to link impact of SDOH on health outcomes

36 CDPM NETWORK ACHEIVEMENTS Common vision and purpose Common LHIN wide approach to and implementation of Best Practice Guidelines Regional indicator development and evaluation Embedding Self Management into primary care practice Embedding health promotion into primary care practice

37 Questions and Discussion!

38 Contact Us Carrie Salsbury – Member SE CHC CDPM Network Gateway CHC (613) 478-1211 Ext 246 csalsbury@gatewaychc.org Laura Cassidy – Chair SEISUG Gateway CHC (613) 478 -1211 Ext 298 lcassidy@gatewaychc.org


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