GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORK - PowerPoint PPT Presentation

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GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORK

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... organizations (e.g. Latin American Diabetes Program, London ON) ... Jessica Meleskie Grey Bruce health network. Lisa Miller Grey Bruce Diabetes Program ... – PowerPoint PPT presentation

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Title: GREY BRUCE CHRONIC DISEASE PREVENTION AND MANAGEMENT FRAMEWORK


1
GREY BRUCE CHRONIC DISEASE PREVENTION AND
MANAGEMENT FRAMEWORK
  • IMPLEMENTATION TOOL KIT

2
WHERE DID THE CDPM FRAMEWORK COME FROM?
  • Wagner (1999)
  • Barr et al (2002)
  • Ontario Ministry of Health and Long term Care
  • The health care system transformation agenda

3
CDPM Framework - Purpose
  • To provide a common policy framework to guide
    efforts toward effective prevention and
    management of chronic diseases
  • To guide Ministry transformation initiatives such
    as
  • Local Health Integration Networks
  • Primary Health Care Renewal, Family Health Teams
  • Public Health Renewal - health promotion and
    prevention initiatives
  • e-Health strategy, HHR strategy
  • Specific chronic disease strategiesTo engage
    ministry stakeholders in a systematic approach to
    addressing chronic disease

4
CDPM Framework Purpose
  • Not just a model changes the paradigm for care
  • A way for conceptualizing care
  • A framework for organizing or re-organizing care
  • Applicable to any system, organization or program

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What Makes People Healthy / Unhealthy?
7
The Transformation
  • TO
  • Wellness orientation
  • prevention at all points of continuum
  • an integrated, interdisciplinary care team
    approach
  • patient centred
  • proactive, complex, continuing care
  • individuals empowered for self-management and
    part of care team
  • FROM
  • Illness orientation
  • prevention not a priority
  • a solo provider approach
  • Provider, disease centred
  • reactive and episodic care
  • limited role for individuals in self management

A System Involving Health Care Organizations Indiv
iduals and Families Communities
8
Why does the CDPM system have that capacity?
  • Focuses on populations
  • Focuses on longitudinal care (creates a system of
    prevention and care)
  • Supports coordination of prevention and care
    along a health continuum
  • Recognizes individuals and communities as
    partners
  • Offers early access to prevention and support as
    well as treatment
  • Offers multi-disciplinary, multi-sectoral
    strategies

9
WHAT IS THE KIT?
  • Written and electronic resources that help groups
    understand the framework, and develop practical
    applications for it
  • Step-by-step support to apply the framework to
    your existing programs, or build new ones
  • A way of establishing a common perspective and
    language between partners when undertaking new
    strategies related to chronic disease prevention
    and management

10
HOW DO WE USE THE KIT?
  • Identify the current or potential program,
    project or partnership initiative requiring
    development/reassessment/redesign
  • Establish a core stakeholder work group
  • Use the resources, references, and steps outlined
    in the tool kit as process supports for
    developmental activities

11
OVERVIEW OF FRAMEWORK APPLICATION THE WORKFLOW
12
CDMP Framework Workflow Understanding the
Framework Step 1 Review the Ontario Chronic
Disease Prevention and Management Framework
diagram. ? Step 2 Review the
Element Definitions in CDPM ? Step 3
Review the Logic Models Applying the Framework
Step 4 Complete Program Feasibility
Checklist ? Step 5 Complete the Logic
Model for Program Planning ? Step 6
Complete the Initiating a Health Program
Checklist ? Step 7 Revise Program (Logic
Model) Plan as required
13
Step I REVIEW THE OCDPM FRAMEWORK DIAGRAM
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15
STEP 2 REVIEW THE ELEMENT DEFINITIONS IN THE
OCDPM DIAGRAM
16
  • Individuals and Families
  • The centre of the CDPM framework
  • Direct involvement and self management of health
    and chronic diseases is key
  • Team members in prevention and care
  • Informed, person-centred choices for living

17
  • Health Care Organizations - make systematic
    efforts to improve prevention and management of
    chronic disease
  • strong leadership (e.g., CDPM champions)
  • alignment of resources, incentives (e.g. Admin
    support, IT support for providers, etc.)
  • accountability for results (e.g., set goals,
    measure effectiveness in improving outcomes for
    clients, population and system )

18
  • Personal Skills Self-Management Support -
    empower individuals to build skills for healthy
    living and coping with disease
  • emphasizing the individuals and families
    central role in their health, and as a member of
    the care team
  • engaging them in shared decision-making,
    goal-setting and care planning
  • providing access to education programs health
    information (e.g. asthma education programs,
    consumer information)
  • behaviour modification programs (e.g. smoking
    cessation)
  • counselling and support services (e.g.
    self-management support groups)
  • integration of community resources (e.g. referral
    to community physical activity programs)
  • follow-up (e.g. reminders, self-monitoring
    assistance)

19
  • Delivery System Design - focus on prevention and,
    improve access, continuity of care and flow
    through the system
  • interdisciplinary teams (e.g., FHTs with defined
    roles responsibilities)
  • integrated health promotion and disease
    prevention (e.g., nutrition and physical activity
    counselling)
  • planned interactions, active follow-up (e.g.,
    care paths, case management)
  • adjustments, innovations in practice (e.g., group
    office visits, central appointment booking
    service)
  • outreach and population needs-based care (e.g.,
    Latin American Diabetes)

20
  • Provider Decision Support - integrate
    evidence-based guidelines into daily practice
  • easily accessible clinical practice guidelines
    (e.g. web-based, interactive)
  • tools (e.g. disease/risk assessment, management
    flow sheets, drug interaction software)
  • provider alerts and reminders (e.g. reminders for
    tests, examinations)
  • access to specialist expertise (e.g. team social
    worker cardiologist at tertiary care centre)
  • provider education (e.g. working in
    interdisciplinary teams, collaboratives)
  • measurement, routine reporting/feedback,
    evaluation (e.g. continuous quality improvement
    loop for target blood glucose levels in client
    population with diabetes)

21
  • Information Systems are essential for enhancing
    information for providers to provide quality
    care for clients to support them in managing
    their disease on a day to day basis and for
    integrating services across health system
  • electronic health records (e.g. personal health
    information, test results, prevention and
    treatment plans)
  • client registries to identify and provide patient
    subpopulations with proactive care, monitoring,
    and follow-up (e.g. tracking systems, automated
    reminders)
  • links (e.g. between team members, care centres)
  • information for clients (e.g. health care advice,
    access to records, community resources)
  • population health data (e.g. demographic, health
    status, risks)

22
  • Healthy Public Policy - develop and implement
    policies to improve individual and population
    health and address inequities
  • legislation, regulations (e.g. smoking by-laws)
  • fiscal, taxation measures (e.g. lowering duty on
    imported fruit)
  • guidelines (e.g. Health Canada food guidelines,
    screening)
  • organizational change (e.g. flex hours, day care
    in the workplace)

23
  • Supportive Environments - remove barriers to
    healthy living and promote safe, enjoyable living
    and working conditions
  • physical environments (e.g. safe air, clean
    water, accessible transportation, affordable
    housing, walking trails, bicycle lanes)
  • social and community environments (e.g. daily
    physical activity in schools, seniors programs in
    community centres, on-site health promotion
    programs in the workplace)

24
  • Community Action - encourage communities to
    increase control over issues affecting health
  • collaboration between the health care sector and
    community organizations (e.g. Latin American
    Diabetes Program, London ON)
  • effective public participation and intersectoral
    collaboration (e.g. community members, private
    sector and schools providing breakfast
    nutrition/physical activity programs)

25
STEP 3REVIEW THE LOGIC MODELS
26
Mission
A systems approach to provide integrated chronic
disease prevention and management services
Roles and Responsibilities
Components
Community Capacity and Integration
Individual and Family Capacity
Health Care Organization
Health Promotion
Roles Responsibility
Roles Responsibility
Roles Responsibility
Primary Prevention
Secondary Prevention
Tertiary Prevention
27
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28
STEPS 4-7 BUILDING YOUR PROGRAM
29
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30
Developing Logic Models
31
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34
  • A VALUABLE REFERENCE FOR PROGRAM PLANNING USING
    THE LOGIC MODEL APPROACH
  • Innovation Network, Inc. (2005) Logic model
    workbook
  • www.innonet.org info_at_innonet.org

35
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36
GB-CDPM FRAMEWORK TOOLKIT PLANNING GROUP
  • Lynda Bumstead Grey Bruce Health
    Unit
  • Nancy Dool-Kontio Southwest Community
    Care Access Centre
  • Cathy Goetz-Perry Grey Bruce Victorian
    Order of Nurses
  • Carolyn Grace Owen Sound Family
    health Team
  • Jessica Meleskie Grey Bruce health
    network
  • Lisa Miller Grey Bruce
    Diabetes Program
  • Susan Pouget Closing The Gap
    Health Care Group Grey Bruce
  • Mary Solomon Grey Bruce Stroke
    Program
  • Michelle Walter Brockton and Area
    Family Health Team
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