chronic care management in a patient's medical home · chronic care model (ccm; figure 2),...

JUNE 2016

BEST ADVICE

Chronic Care Management in a

Patient's Medical Home

©The College of Family Physicians of Canada 2016All rights reserved.

junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 1

INtrodUctIoN

Within the Patient’s Medical Home* (PMH), the following guiding principles1 promote comprehensive care and response to the public’s needs:

• Thepatient’spersonalfamilyphysicianshouldworkcollaborativelywiththeother team members to provide a comprehensive range of services for people of all ages, including managing undifferentiated illness and complex medical presentations

• ThePMHshouldprioritizedeliveringevidence-basedcareforillness,injuryprevention,and health promotion, reinforcing these priorities during each patient visit

• ThehealthcaresystemshouldsupportPMHstoensuretheirkeyroleinmanaging and coordinating care for patients with chronic diseases, including mental illness

• Self-managedcareshouldbeencouragedandsupportedaspartofeachpatient’s care plan

IllnessanddiseaseinCanadahaveshifteddramaticallyfromacute,communicableillnessestoa prevalence of chronic diseases. Chronic care management of diseases—including diabetes, hypertension,osteoarthritis,andmentalillness—isasignificantchallengefacingCanadacurrentlyandinthefutureduetoprojectedgrowthinourseniors’population.1 As populations age,theprevalenceofchronicdiseaseinsocietyrises.2

Chronicdiseasesarenon-communicable,long-lastingillnessesthatcanbeinfluencedbyhealth-relatedbehaviours.Inrecentyears,evidencehasshownthatthesediseasesareatepidemic proportions.3 In Canada, the number of deaths attributed to chronic disease is rising,andchronicdiseaseratesareincreasingatapproximately14%eachyear.4Thereisanincreased prevalence of people living with multiple chronic diseases (comorbidities), due to an increase in our seniors’ population.2

Although chronic diseases occur most often in olderadults,theyarenotexclusivetothatagegroup. Chronic diseases are increasing faster amongCanadiansbetweentheagesof35and64,compared with those age 65 or older. Children andyoungeradultsareshowingincreasingratesof chronic disease, and as a result are living with chronicdiseasesforalongerperiod,makingchroniccaremanagementextremelyimportant.4

Chronic diseases can have a significant impact on child development. Children and adults experience differenttypesofdiseases.Themostfrequently

*Patient’s Medical Home: http://patientsmedicalhome.ca.

Eighty-three per cent of Canadians age 65 and older report having at least one chronic disease.7 Nearlyone-quarterofallCanadianseniors are living with comorbidities, reporting three or more chronic diseases.Theestimatedprevalencesreported for the following diseases among adults are:

Diabetes: 9.3%8

Hypertension: 22.7%9

Osteoarthritis and arthritis: 15.3%10

2 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016

reported chronic diseases among seniors are high blood pressure and arthritis.5 Children, on theotherhand,morecommonlyfaceasthma,diabetes,andcancer.6

Providingpatient-centredprimarycarecancontributetoimprovedclinicalhealthoutcomesforpatientswithchronicdiseases.PMHfamilyphysician-ledteamsarethecornerstoneofeffective chronic care management.

obJEctIvE

Theobjectiveofthisguideistoprovideactionableadvicetofamilyphysiciansaboutchroniccaremanagementinfamilypracticesettings.Thegoalsaretoimprovequalityoflife,preventsecondaryconditions,minimizedistressingsymptoms,andpreventtheonsetofdiseasesforthosewhoareatrisk.11

Whilethisguideappliestoalltypesoffamilypractices,thestrategiesdescribedinvolvemanyimportantcomponentsoftheCollegeofFamilyPhysiciansofCanada’s(CFPC)PMHmodel.

backgroUNd

Chronicdiseases,whilecomplex,sharecommonriskfactors. Whilesomebackgroundriskfactors, such as age and genetic composition, cannot be changed, others can be modified.11

Commonbehaviouralriskfactorsforchronicdiseasesincludetobaccouse,unhealthydiets,physicalinactivity,andalcoholabuse.12 Compellingevidencesuggeststhatunhealthybehavioursandexcessivebodyweightareassociatedwithmanychronicdiseases,includinghypertension,type2diabetes,coronaryheartdisease,osteoarthritis,andsomecancers.

Morethan60%ofCanadianadultsareoverweightorobese,13and25%ofCanadianchildrenareoverweightorobese,placingthematahigherrisktodevelopchronicdiseases.14 Indigenouscommunitiesareatanevengreaterrisk,reportinghigherratesofdiseasessuchasheart disease, diabetes, cancer, and asthma.4

Socialdeterminantsofhealthshapebehaviouralriskfactors.Povertycanbeaprimarycauseofchronicdiseases,asitincreasestheriskofpoornutrition,tobaccouse,lowlevelsofphysicalactivity,andalcoholabuse.ThisissupportedbyevidencethattheimpactofchronicconditionsonqualityoflifeismostpronouncedforCanadianswiththelowestsocio-economicstatus.15

Therelationshipbetweenchronicdiseasesandsocialdeterminantsofhealthiscloselylinked—somepeopleexperiencepovertyduetotheirillness,whileothersareillbecauseoftheirsocio-economicconditions.2 Figure 1 shows the complex drivers that interact to influence the rates of chronic disease.


AccordingtotheCommonwealthFund,healthcareprovidersoftenmisstheopportunitytoengagechronicallyillpatientsandhelpthemmanagetheirownhealthcare.Chroniccaremanagementcanprevent,delay,andcontrolchronicdiseasestomitigatetheirprofoundsocialandhealthconsequences.Atleast80%ofprematureheartdisease,stroke,andtype2diabetes,aswellas40%ofcancers,couldbepreventedwithactivemanagementinterventions.17

the role of family medicine

Familyphysicianscanhelpaddresstheincidenceofchronicdiseasesandinfluencetheeffectsbyimplementingpracticalchroniccaremanagementstrategiesintheirpractices.Evidencedemonstratesthatwell-organizedfamilypracticeshaveasignificantroletoplayinmitigatingmanyoftheriskfactorsandcostsassociatedwithchronicdiseases,contributingtobetteroutcomesandhelpingpatientsnavigatethehealthcaresystem.18,19,20,21

Activemanagementstrategiescanhelppreventordelayimmediateorlong-termcomplications.Forexample,chroniccaremanagementofpatientswithlong-termdepressioncanbenefittheirhealth-relatedqualityoflife.Byworkingwithotherhealthcareprofessionalsto deliver the most appropriate care, familyphysicianscanbuildatrustingrelationshipwithpatientsthatallowsforcontinuityofcareandcomprehensiveness,whichcancounterthecomplexities of chronic comorbidities.20

Combiningtheseelementsofcare,thePMHmodelisideallysuitedformanagingchroniccare.Thepatient-centredapproachisthemostappropriateforprovidingchroniccaremanagementforpatientswithchroniccomorbidities,bymanagingdiseasessimultaneously.

Causes of chronic diseasesUNDERLYINGSOCIOECONOMIC,CULTURAL, POLITICAL AND ENVIRONMENTALDETERMINANTS

Globalization

Urbanization

Population ageing

COMMON MODIFIABLERISK FACTORS

Unhealthy diet

Physical inactivity

Tobacco use

NON-MODIFIABLERISK FACTORS

Age

Heredity

INTERMEDIATE RISK FACTORS

Raised blood pressure

Raised blood glucose

Abnormal blood lipids

Overweight/obesity

MAIN CHRONICDISEASES

Heart disease

Stroke

Cancer

Chronic respiratory diseases

Diabetes

Figure 1: Drivers that influence chronic disease

ReproducedwithpermissionfromWorldHealthOrganization16


ChroniccaremanagementshouldbeledbyfamilyphysiciansandthePMHteam,involvingthecommunitiesinwhichtheirpatientsreside.Ifproperlyorganizedandsupported,theinterprofessionalPMHteamscanhelppreventanddelaymanychronicdiseasesaswellassignificantlymitigatetheireffects.1

ModEls For chroNIc carE MaNagEMENt

Manymodelshavebeendevelopedformanagingchroniccare.Althoughtheyincludedifferentelementsorstrategies,theyoftenhavecommonrecommendations2fortacklingchronic care management, such as:

• Promotingproactivecare

• Identifyingneededservicesbasedonriskstratification

• Acknowledgingprimarycareasthehubformanagementsupports

• Usinghealthinformationsystems

• Buildingcommunitypartnerships

• Promotingself-management

• Usingbestpracticeguidelines

Somechroniccaremanagementmodelsuseadisease-specificapproach,whichmaynotbe helpful in managing complex patients with comorbidities.11 When adapting a chronic caremodeltofamilypractice,thefollowingstrategies11mayhelpwithdevelopinganintegrated approach:

• Streamlineapproachesforrelatedconditions, such as a common program formetabolic-syndromeconditionslikediabetesandhypertension

• Promoteself-managementtoolsthatapplytomanychronicconditionsandcanhelppatients with comorbidities manage their overall care

• Fosterafamily-centredapproach;researchhasshownthatfamilymembersoftenplaya significant role in managing chronic conditions

A helpful resourceforfamilyphysiciansusingbestpracticeguidelinesistheCanadianTaskForceonPreventiveHealthCare,establishedbythePublicHealthAgencyofCanadatodevelopclinical practice guidelines that support primaryhealthcareprovidersdeliveringpreventive health care. For example, the taskforcerecentlydevelopedguidelinesfor Obesity in Children.†

Prevention in Hand‡ (PiH), a CFPC initiative, provides access to a user-friendlywebsite and a mobile application that are valuable health care resources for health professionals and thepublictoeasilyaccesscurrentandaccurate information about preventing chronicdiseases.Familyphysicianscan access resources for professional guidelines as well as tools that support behaviour change.

†CanadianTaskForceonPreventiveHealthCare– ObesityinChildren:http://canadiantaskforce.ca/ctfphc-guidelines/2015-obesity-children.

‡Prevention in Hand (PiH): www.preventioninhand.com.


TheChronicCareModel(CCM;Figure 2),alsoknownastheWagnerModel,isoneofthemostcomprehensivechroniccaremanagementmodelsandhasbeenadaptedtoavarietyofsettingsanddiseases.TheCCMactsabasisforPMH-likemodelsfocusedondeliveringproactive,planned,andevidence-basedchroniccaretopatients.22Themodeladvocatesamulti-facetedapproachforprimarycareteamsandfocusesonproductiveinteractionsbetween informed, empowered patients and prepared, proactive practice teams.23

Figure 2: TheChronicCareModel

ReproducedwithpermissionoftheAmericanCollegeofPhysicians23

Figure 2: The Chronic Care Model

Community

Functional and Clinical Outcomes

Health System

Resources and Policies Organization of Health Care

Self-managementSupport

DecisionSupport

DeliverySystemDesign

ClinicalInformation

Systems

Informed,Activated

Patient

Prepared,Proactive

Practice TeamProductive

Interactions

Reproduced with permission of the American College of Physicians23

Thefollowingareexplanationsofthemodel’skeycomponents:3

• Self-managementsupport:providingself-managementtoolstohelppatientsandtheirfamiliesacquiretheskillstomanagetheirillnesses

• Deliverysystemdesign:creatingpracticeteamswithavisionofcreatingvariousrolesfor practitioners to implement preventive and management services for those who face chronic illnesses

• Decisionsupport:integratingevidence-basedclinicalpracticeguidelinesintodailypractice

• Clinicalinformationsystems:usingremindersystemstocomplywithpracticeguidelines,andregistriesforplanningindividualandcommunity-basedcare

• Communityresources:establishingcommunitypartnershipstoenhancesupportsforpatients and communities


• Healthcareorganization:organizingtheserviceanddeliveryofthehealthcaresystemto support chronic care management

In Canada, various provincial health authorities use different chronic care models to developcomprehensivechroniccaremanagementstrategies.Alberta,BritishColumbia,andNewfoundlandandLabradorusetheExpandedCCM.Itgoesbeyondaclinicalfocus to include elements of the population health promotion field, which encompasses preventionefforts,recognitionofthesocialdeterminantsofhealth,andenhancedcommunityparticipation.24TheOntarioChronicDiseasePreventionandManagementFrameworkwasdevelopedusingtheCCMandtheExpandedCCMtocreateanapproachthatisevidence-based,population-based,andclient-centred.25 While the specific model used in each provinceorterritorymaynotbethesame,theysharesimilarfeaturesandaimtointroducestrategies to prevent chronic diseases and manage chronic care.

stratEgIEs For INcorporatINg chroNIc dIsEasE MaNagEMENt

Thefamilypracticeplaysacentralroleinpreventingchronicdiseasesandmanagingchroniccare.Chroniccaremanagementshouldtakeplacethroughouttheprogressionofchronicdiseases—fromexperiencingtheriskfactors,todevelopingtheintermediateconditions,to arriving at the disease endpoints. Patientsateachstagerequirevariouspreventionandmanagementinterventionstoensuretheiroptimalhealth.Familyphysiciansshouldbeawareofdifferentfactorsandconditionstoaddresstheseeffectively.12

Whilemanysolutionsarerootedincomplexsystem-levelchanges,thisguidefocusesonpracticalstrategiesthatindividualfamilyphysicianscanadoptbyreorganizingaspectsoftheirpracticesandusingavailableresources.Thisguideoffersrecommendationsforeffectivelyapproachingchroniccaremanagementonthreelevels—inthepractice,inthecommunity,andinbroaderadvocacy.

IN thE practIcE

promoting self-care

Thegoalofself-managedcareshouldbebuildingconfidenceinpatientsandtheirpersonalcaregiverstohelpthemdealmoreeffectivelywiththeirillnessesandimprovetheirhealthoutcomes.Physicalactivity,nutrition,adherencetomedications,andself-monitoringarecomponentsofeffectiveself-careformanychronicconditions.Manypatientsmayfacechallengeswhenfollowingrecommendedguidelines,addingcomplexitytothesupportroleoftheircareteam.Topromoteself-caresuccessfully,practicesneedappropriatehumanresources(primarycareteams),adequatetraining,andongoingimplementationsupportforthepatients.26

In order for chronic care programs to be effective, patients must be involved as partners in theircareandsupportsmustbeconsistentlyavailable.12Keyfeaturesofself-managementinclude:


• Workingwithpatientstoidentifyself-managementtoolstohelpthemtrackandmonitorhealthybehaviours,aswellasbuilding confidence2

• Providingpatientsandtheircaregivers with information aboutcommunityandsocialservicesthatmayimprovetheirhealth2

• Addressingpatientdistressrelated to a chronic disease27,28

• Improvingpatientself-efficacybydiscussingreal-lifesituationsand challenges that patients mayfaceandusingproblem-solvingskillstoaddressthem29

• Fosteringpositivepatient-physicianinteractionsbyaskingquestionsandlisteningtopatient responses to ensure that problems are identified from the patient’s perspective26

• Includinggoal-setting,planning,andproblem-solvingstrategiesduringanappointmenttohelppatientsdeveloparealisticactionplanandtoaddressanyimmediateconcerns26

• Addressinghealthliteracyissuesandmedicalobstaclestoself-managementbyensuringthatpatientsunderstandgoals,expectations,medicalterminology,andmetrics.26 For example, one proposed health literate care model30 suggests that health careprovidersshouldassumethatpatientsmaynotunderstandhealthinformationrelevanttotheircare,andassertsthathealthliteracyinterventionswillimprovetheoutcomes for patients in managing their chronic diseases. For more information about addressinghealthliteracyinthepractice,refertotheBestAdviceguide Health Literacy.§

Varioustoolshavebeendevelopedtohelpcareprovidersenableself-managementsupport.Appendix A contains practical resources when engaging in conversations with patients aboutself-carepractices.The7AsofBehaviourChange,inAppendixB,isausefultoolinpreventioncounselling.Consideringafamilyphysician’stimeconstraints,haveotherteammembersresponsibleforusingthesetoolsandworkingwithpatientsonself-managementstrategies.

§ BestAdviceguideHealth Literacy: http://patientsmedicalhome.ca/resources/best-advice-guides/best-advice-guide-health-literacy-patients-medical-home.


Maintaining ongoing physician-patient interaction

Closelyrelatedtoself-managementistheideaofbuildingpatient-physicianpartnerships.Strongrelationshipsbetweenpatientsandmembersoftheircareteam,includingnurses,pharmacistsanddietitians,makefamilypracticesettingsanappropriateavenueforeffectivechroniccaremanagement.Provider-patientconversationsaroundchroniccaremanagementcan cover:

• Education

• Communitysupports

• Caremodifications

• Patientgoals

• Negotiation

• Evaluationoftreatmentplans

Theseongoingconversations,whichempowerpatientstobeactiveparticipantsintheirowncare, have the potential to increase chances of adherence to care plans and of improved health outcomes.32,33

Auniquewaytofacilitateongoinginteractionissecuremessagingaswellastelephone-andInternet-basedcommunication.Theseinteractionshavebeenshowntoimprovehealthoutcomesandtheydonotrequirepatientstoincuradditionaltimeorcosttravelling,allowingfor easier communication more often.34ItisimportantforfamilyphysicianstounderstandthecomplexitiesassociatedwithWeb-basedcommunicationsbecauseofconcernsoverprivacy,safety,andtimeliness.ForsuggestionsaboutmanagingWeb-basedinteractionswithpatients,refer to the Canadian Medical Protective Association’s Using email communication with your patients: legal risks.†

Case study: Integrated Health Network, British Columbia

In Port Alberni, British Columbia, patients whose family physicians are part of the Port Alberni Integrated Health Network are offered various chronic care management and wellness programs, including the Chronic Disease Self Management Program, a 6-week workshop that helps patients with chronic diseases better manage their symptoms. The program goal of promoting self-confidence and motivation is accomplished through the workshop’s information and practical skills. The workshops cover a variety of topics, including healthy eating, starting and maintaining exercise, pain and fatigue management, communicating with health care providers, managing medications, and so on.31

† TheCanadianMedicalProtectiveAssociation–Usingemailcommunicationwithyourpatients:legalrisks:www.cmpa-acpm.ca/-/ using-email-communication-with-your-patients-legal-ris-1.


promoting timely access

Offeringtimelyservicesisanessentialcomponentofchroniccaremanagement,whichpromotescontinuityofcarebetweenpatientsandtheirprimaryprovider.Manypractices,particularlylargerpracticeswithchronicallyillpatients,preferschedulingmodelsthatofferbothscheduledappointmentsandsame-dayschedulingwhendealingwithcomplexconditions.35

• Scheduledappointmentsallowphysiciansandpatientstoplancareappointments,wherechroniccareissuesareproactivelymanaged.Theyfocusonaspectsofcarethattypicallyarenotdeliveredduringanacutecarevisit.Regularlyscheduledvisitsallowfamilyphysicianstodeliverevidence-basedclinicalmanagementaswellaspatientself-management.36 Planned care visits are also avenues that support preventive care that is not part of chronic diseases, to ensure that preventive tests are completed.

• Same-dayvisitsgivepatientstheopportunitytoseetheirphysicianpromptlywhencareisneeded.Same-dayvisitscanbereservedforroutine(ie,non-chronichealthconcerns) or urgent visits to allow patients to see their care provider as soon as possible.33,37

Thenumberofsame-dayappointmentsreservedineachpracticecanvaryandshouldbeinproportiontoneed,dependingontheaveragenumberofworkdaysthepracticehas.Itisimportanttonotethatschedulingfollow-upvisitscanbecriticalinassistingboththepatientandphysicianwithmanagingchroniccare.36Extendingofficehourstooperatebeyondtypicalbusiness hours also provides prompt access to care for patients who otherwise would not see theirfamilyphysicians.

RefertotheBestAdviceguideTimely Access¶ for more information on effective strategies to promotetimelyaccessinaprimarycaresetting.

Employing patient rostering

Patientrosteringisaprocessbywhichpatientsregisterwithafamilypractice,familyphysician,orteam.Rosteringcanpromotedevelopingandstrengtheningthecontinuingrelationshipbetweenpatientsandtheirfamilyphysician,nurses,andotherteammembers.Thislong-termrelationshipiscriticalforeffectivechronicdiseasemanagement.

Patientrosteringalsofacilitateseffectivepreventivecareandsupportscontinuousqualityimprovementactivitiesinthepractice.Rosteringhelpsfamilyphysiciansandteamsidentifypatientswithchronicdiseases,enablingthemtoprovideimportantpreventiveandmanagement services.39

Accessingsummaryinformationabouttheirpracticepopulationcanenablephysicianstoensuretheirpracticesarestaffedwiththeappropriateteammembers.Forinstance,ifmany

¶BestAdviceguide Timely Access to Appointments in Family Practice: http://patientsmedicalhome.ca/resources/best-advice-guides/best-advice-guide-timely-access.


patientshavediabetes,theleadphysicianmayconsideremployingadiabeteseducatorasapart of the team.

RefertotheBestAdviceguidePatient Rostering§ for further information about the benefits ofpatientrostering,andadviceforfamilyphysicianswhohaveimplementedrosteringorareconsidering it.

Using group visits

Group visits (appointments, sessions) can help patients with chronic diseases.1 Patients should be involved in setting the agenda and discussing care management during these visits.40 Thisallowsforproductiveconversationsaboutstrategiestomanagecareinanempoweringmanner.Familypracticesthathaveusedgroupvisitsreport:

• Increasedpatientandprovidersatisfaction

• Increasedpatientself-management

• Decreasedprevalenceofchronicdiseases

Leadingsuccessfulgroupvisitsrequirescarefulplanningaswellashealthcareteamcollaborationtoensuretheefficientdeliveryoftheservices.Examineprovincialorterritorialbillingguidelinesforgroupmedicalvisitsforinformationabouthowtheycanbefinanciallysupportedinafamilypractice.Formoredetailsaboutsettingupgroupvisitsinafamilypractice,refertotheGeneralPracticeServicesCommittee(BC)GroupMedicalVisitsTools&Resources.‡

§ BestAdviceguidePatient Rostering in Family Practice: http://patientsmedicalhome.ca/resources/best-advice-guides/best-advice-guide-rostering.

‡GeneralPracticeServicesCommittee(BC)–GroupMedicalVisitsTools&Resources: www.gpscbc.ca/what-we-do/professional-development/psp/modules/group-medical-visits/tools-resources.

Case study: Group visits, Alberta

A family practice in Taber, Alberta, includes a significant percentage of elderly patients with complex needs. Using panel information from electronic medical records, 14 patients (age 65 and older) were identified as appropriate for group visits based on their cognitive function, mobility, and interest in participation. These patients had an average of 5.7 diagnoses, and required an average of 18.7 visits per year.

Group visits were provided monthly and run by the core family practice team, including the family physician, medical office assistant, and registered nurse. Other presenters often attended, as well as the local pharmacist, community nurse, medical students, and residents. The visits included time for individual reviews of physical conditions and medications, a presentation on a topic of the patients’ choosing, as well as group interaction and questions to the presenter and/or physician. A nutritional break was important for social interaction.

Typically, 6–8 individual appointments were provided in an average 2.5 hour period. By offering group visits, all 14 patients could be seen during that same time frame. Results included improved clinical outcomes, patient and provider satisfaction, patient self-management, and a reduced requirement for appointments.


Working in teams

Interprofessionalprimarycareteamscanimproveclinicalhealthoutcomesforpatientswithchronicdiseases,includingtype2diabetesanddepression.41Akeycomponentofprovidingeffectivechroniccaremanagementservicesisensuringthatprimarycarepracticeshavetheappropriate mix of trained staff.2Primarycarepracticeswithmultidisciplinaryteamsexcelatrecommendingpreventiveservicesandcommunity-basedprograms.

Practicesmayfinditusefultocreateahumanresourcesplantoensureanadequatemixandnumbers of providers to offer the proper support for patients with multiple chronic conditions. Membersofthehealthcareteamcanassistwithplanning,counselling,andfollow-upservicesthattypicallyfallonthephysicianbutcanbemanagedbyotherteammembers.14

Patient care benefits from the expertise of various professionals including nurses, pharmacists, socialworkers,andnutritionandexercisecoaches.20 In addition to having the right compositionthatrespondstocommunityneeds,itisimportantforteamstocommunicateefficientlybymeetingtodiscusspatientchallengesanddevelopacoordinatedplan.

Overall,patientsbenefitfromhealthcareteamsastheyallowthecaretofocusonwellness,prevention, and patient education.20ThePMHmodelstronglyemphasizescollaborativeinterprofessional teams and highlights the importance of communication between team members.

Theinteractionbetweenfamilyphysiciansandotherspecialistsisalsoessentialinintegratingcareplansthatresultinimprovedcaremanagementandhealthoutcomes.Familyphysicianscancoordinatecarewithotherspecialistsandreferralservices,workinginpartnershipwiththe patient and other health care professionals to deliver the most appropriate care.

Case study: Primary care network, Alberta

In Alberta, health care teams work together in primary care networks (PCNs)—a network of doctors and other health care providers, such as nurses, dietitians, and pharmacists, working together to provide primary care services. A PCN can be composed of one clinic with many physicians and support staff, or several doctors in various clinics in a specific geographic area. Each PCN has the flexibility to develop programs and provide services in a way that meets the needs of its local patient population.42 This model of care delivered by a multidisciplinary team has proven to be successful, reporting increased patient satisfaction with wait times, better use of screening tools as part of health promotion and disease prevention, increased access to chronic disease management, and a decreased use of emergency room services.43


adopting electronic medical records

An electronic medical record (EMR)isadigitalmedicalrecordthat clinicians maintain for eachpatient.PhysicianscansetupEMRstocollectpatientinformation about demographics, medical and drug histories, and diagnostic information such as laboratoryresultsandfindingsfrom diagnostic imaging.44EMRscansupportchroniccaremanagementbyhelping:45,46

• Identifypatients/populationswhoareat-riskorneedfollow-up

• Targetservicestopatientsbasedontheirlevelofrisk

• Improvescreeningservices

• Improvecasemanagementforpatientswithchronicdiseases

• Maintaincommunicationwithpatientsthroughpatientportals

• Enhanceadherencetochangesinclinicalguidelines

• Monitorhealthconditionsonaregularbasis

EMRsarewidelyrecognizedasanessentialtooltocoordinatecare,particularlyforpatientswithcomorbiditieswhomaybeseeingvarioushealthcareprovidersfordifferentconcerns.20 EMRsoftenhelpmanagepatientsbyprovidingreadilyavailableaccesstopatientdatabeforeand during a visit. Positive changes can result from preventive care reminders being sent to thephysician,withalertsforanyoutstandingscreeningtests.47,48

PracticesusingEMRsarealsoabletoaccesspatientfilesinlesstimethanpaper-basedclinics.41,49EMRsareausefuldatacollectiontoolthatallowsphysicianstotrackpatientinformationandmeasureprogress.Theycansortthroughpatientfilesbymedicationuseorbydiagnosis.Asaresult,theycanquicklyandconfidentlymakechangesincare,suchas medication recalls and treatment guidelines.41Thistranslatesnotonlytosignificanttimesavings,butalsotohigh-qualitypatientcare.

TheBestAdviceguideAdopting EMRs in a Patient’s Medical Home‡ provides practical adviceaboutwhattoconsiderwhenimplementinganEMRsystem.

‡BestAdviceguide Adopting EMRs in a Patient’s Medical Home: http://patientsmedicalhome.ca/resources/best-advice-guides/best-advice-guide-adopting-emrs.


Evaluating practice strategies

Toensurethatthestrategiesprovidedthroughoutthisguideareusedsuccessfully,itisimportant that practices implement evaluation measures that are suitable for their patients andpracticepopulation.Topromotecontinuousqualityimprovement,metricscanbeusedtoevaluatechroniccaremanagementinterventionstoassesstheirefficiency.Metricswillvarydependingontheservicesbeingoffered;someusefulmetricstoconsiderinclude:50

• Programoutputs(eg,access,continuity,programallocationsandexpenditures)

• Panelsize

• Screeningrates

• Patientandprovidersatisfaction

• Individualandcommunity-levelhealthoutcomes(eg,prevalenceofriskfactorsandchronic disease, social determinants)

• Intermediateprogramoutcomes(eg,communityengagement,coalition-building,policydevelopment)

• Qualitativeindicators(eg,informationfromspecificclientandcommunitygroups)

Thisguidefocusesprimarilyonwhatphysicianscandowithinthefourwallsoftheirpractices,themicrolevel.However,community-levelactivityandbroaderadvocacycanalsobeveryeffective in chronic care management.

IN coMMUNItIEs

developing community partnerships

Practicesthatlinkclinicalservicesandcommunitysupportscanhelpensurethatpatientswith,orathighriskof,chronicdiseaseshaveaccesstoneededresourcestopreventormanagetheirconditions.Referringpatientstoaccessibleandeffectivecommunityprogramscanimprovetheirqualityoflife,helpingthemavoidcomplicationsandreducetheirneedformorehealthcareservices.Developingcommunitypartnershipscaninclude:51

• Learningaboutexistinghealthpromotionservicesofferedinthecommunity(eg,tobaccocessationlines,supportgroups,etc.)andlinkingpatientstothemwhenneeded

• Collaboratingwithotherlocalhealthcareprofessionalswhomaybeprovidingcaretothe practice’s patients

• Establishingpartnershipswithotherhealthservices(eg,hospitals,othercareproviders,etc.)toimprovecommunityandpopulationhealth,usingcommunitybenefitinvestmentsandadvocacy


broadEr advocacy

addressing social determinants of health

Chronicdiseasescannotbeaddressedwithmedicalcarealone.Thebestwaytodealwithchronicdiseasesistoavoidgettingtheminthefirstplace.Topreventchronicdiseasesfrombecoming more prevalent, root causes—which are often based in social determinants of health—must be addressed.

Manyfamilyphysiciansrecognizethatitisdifficulttotreattheimmediatehealthconcernsoftheirpatientswithoutaddressingtheunderlyingsocialconditionsthatleadtopoorhealth.Thesocialconditionsinwhichpatientslivecontributesignificantlytotheirhealthstatusandtheirlikelihoodtodevelopchronicdiseases.Familyphysicianshaveanimportantandpowerfulvoicetouseinadvocacyforsocialandhealthpoliciesthatwillhaveasignificantpositiveimpact on their patients’ health.

Case study: Family health team, Ontario

The South East Toronto Family Health Team (FHT) formed a partnership with Toronto Parks, Recreation and Forestry in the FHT’s Healthy Weights Program. A therapist from Parks and Recreation worked one-on-one with patients to develop a personalized action plan for physical activity based on the patient’s needs. The goal was to get overweight patients more physically active, based on their personal interests.

The therapist collaborated with the FHT dietitian and social worker. The social worker’s role was to complete a series of cognitive behavioural therapy classes with patients enrolled in the program and monitor behaviour changes. At the end of each class, 30–45 minutes of exercise was incorporated. This partnership worked effectively, as it built on the team members available in the FHT and connected patients with community supports to improve their health.4

Case study: Family practice partners, Prince Edward Island

Family practices in Prince Edward Island, such as Sherwood Medical Centre in Charlottetown, partnered with the diabetes education centre to provide diabetes care. Nurses from the centre visited the family practice offices once a month to provide care for complex patients chosen by the family physicians, which improved diabetic control for the patients. The opportunity for face-to-face communication was informative for both the patients and their family physicians.


FosteringfamilypracticesthatrespondtocommunityneedsarekeyfeaturesofthePMHmodel.TheBestAdviceguideSocial Determinants of Health§ provides practical advice for health professionals about improving their patients’ social determinants of health.

supporting environmental approaches

Anenvironmentalapproachreferstoaninitiativetochangepoliciesandphysicalsurroundingsthatinfluencehealthbehaviours.Whenimplementedincommunitysettings,suchasschoolsandworkplaces,environmentalapproachescanpromotepositivehealthbehaviours and help prevent and manage chronic diseases.45Examplesofenvironmentalapproaches include:46

• Urbandesignthatencourageswalkingandcycling

• Smoke-freeregulationinpublicsettings

• Moreaccesstohealthyfoods;forexample,supportingfoodbanksorcommunitygardens

coNclUsIoN

Thesepracticalguidelines,whichaligndirectlywiththePMHframework,canassistapracticewith implementing supports that prevent andmanagechronicdiseases.Thiscanleadto improved patient outcomes, fewer health complications, and increased preventive servicesandcommunitysupports.

Duetotheiruniquerelationshipwithpatientsandthebroadrangeofservicestheyoffer,familyphysicianshaveakeyroletoplayinchroniccaremanagement.Thestrategiesprovidedinthispapercanhelpfamilyphysicianspromotechangewithindividualpatientsandsocietyatlarge.Bycollaboratingwithhealthcareteamsandpatients,familyphysicianscandeliverpatient-centredcarethatmitigatestheeffectsofchronic diseases.

§BestAdviceguideSocial Determinants of Health: http://patientsmedicalhome.ca/resources/best-advice-guides/ best-advice-guide-social-determinants-health.


Appendix A: Self-management support tools

targEt practIcEa model for patient-physican interaction for self-management

Target PracticeOptions for self-management of your chronic conditions

Circle all conditions that you manage: diabetes, asthma, hypertension, arthritis, heart disease, others: _______________________________________

Name: _______________________________________

Date: _______________________________________ Agreements:• The circle includes a variety of self-management skills … they ALL may be highly important to your health, but you don’t need to do ALL of them ALL the time

• If there is a topic that is more important to you, add it to the circle

• Nobody does all of these perfectly

• It is best to work on one or two at a time

• This is a partnership, you will not be pushed

• You choose which one(s) you want to discuss today The steps outlined below give an interactive feedback loop between physician and patient.

Checking blood sugar

Smoking

Fatigue

Referrals

Relaxation and play

Eating: food choices, portion sizes,

time of day

Checking feet

Using inhaler

Regular visitsTaking medicine

Physical activityand flexibility

Drinking

Agree: Collaboratively select one topic from the

circle. Ask: What do you want to know about this topic?

Start here

Ask: What are your concerns about your condition(s)? What do you want to happen in your life regarding your conditions? What would it take for that to happen?

What are the barriers?

Agree: Identify goals and action plan to address patient’s

concerns.

Advise: Provide the specific information requested by patient

and family.

Ask: How confident are you in your ability to carry out your action plan, on a scale of 0 to 10? If confidence level is less than 7, what would it take to get your confidence rating

to 7 or more?

Reproduced with permission from Institute for Healthcare Improvement.

Support: Follow up and fine-tune action plan. Inquire by phone or in

planned encounter about challenges and success. Repeat process for problem solving and

making new action plans.

Assist: Clarify goals and action plan, using

personal action plan form.


pErsoNal actIoN plaNhelping patients develop a plan for healthy behaviours

Reproduced with permission. Partnering in Self-Management Support: A Toolkit for Clinicians. Cambridge,MA:InstituteforHealthcareImprovement;2009.

4 x/

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hen:

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Appendix B: Model of self-management support

sEvEN as ModEl oF sElF-MaNagEMENt sUpport‡

• Ask permission to discuss, explore readiness for change, and use motivational interviewingtomovepatientsalongthestagesofchange.Askaboutpreferredways to learn.

• Assessreadinessforchangeaswellaslifestyleissues,health-relatedriskfactorsandbehaviours;understandingofdiseaseandaskforanyquestions;assessnutrition,physicalactivity,psycho-social,economic,occupationalandenvironmentalfactors.Assessforanyliteracyissues.

• Advisewithclear,specific,andpersonalizedadvicetopromotebehaviourchangeandknowledge;useeffectivechangeapproach.Useplainlanguageandappropriatelearningmaterialsmatchedtopatient'slearningstyle.

• Agreeoncommonground/shareddecisionmakingaboutthenatureoftheproblem,thetreatmentgoals,andthephysicianandpatientrolesintheplan.Agreeonrealistic,modest,andachievablegoalstohelpreducenegativelifestylebehavioursandpromotepositivebehaviours.Focusonmotivationandability.

• Assistthepatientinachievingagreed-upongoalswithavarietyoftechniquesincludingteachback,behaviourchange,self-help,orcounselling.Providetools,information,andsupportsasneeded.Helppatientsovercomebarriers,identifystrategiestoimproveadherence, and reward specific behaviour to increase motivation.

• Arrangefollow-upstohelpandsupportthepatient.Adjusttheplanand/orreferasneeded.Involveotherhealthcareproviders/teammemberswhennecessary,includingcommunitysupportgroupsandprogramsthatsupportchronicdiseaseself-managementthataretailoredtothepatient,andthatconsidercultureandliteracy,etc.

• Advocateatacommunityleveltopromotesystemschangethathelppatientsliveinanenvironmentthatsupportsandencourageshealthylifestylechoicesandoptions.Promotehealthybehavioursinthepracticepopulationasawhole,intheclinicenvironmentandatthecommunitylevel.Thiscanincludeadvocacyforspecificprogramstoimproveliteracyandaddressothersocialdeterminantsofhealth.

‡AdaptedfromPlourdeG.6AsModelofCounsellinginObesity[Letters],andVallisM,Piccinini-VallisH,SharmaA,FreedhoffY.Re:6AsModelofCounsellinginObesity[Reply]. Can Fam Physician. 2013 Feb 7. Available from: www.cfp.ca/content/59/1/27.abstract. Accessed 2016 April.


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