CALASS 2006 Implementing Integrated Models of Prevention & Management of Chronic Illness Care:...

CALASS 2006

Implementing Integrated Models of Prevention & Management of Chronic Illness Care:Barriers & Facilitators in the Canadian Context

Jean-Frédéric Levesque, MD, PhD

Debbie FeldmanCaroline Dufresne

Pierre BergeronBrigitte Pinard

Annual Research Meeting - AcademyHealthWashington

June 8th 2008

Jean-Frédéric Levesque, ARM Washington, 2008

A chronic care transition

• Increase in life expectancy/Reduction of lethality– Ageing– Increase in prevalence of chronic illness

• Multi-factorial problems– common determinants– interaction of morbidities– multiplicity of actors involved


Implementation of the CCM

• Doctors reporting:– well prepared for managing of chronic illness: 55%– capacity to generate list of patients by diagnoses:

26%– tests are sometimes/often repeated because results

are not available: 20%

– receiving almost all information on references: 62%

• Patients reporting:– reception of a self-management plan: 33%

– receiving reminders for preventive services: 38%

(Source : Commonwealth Fund 2007)


• Patient Assessment of Chronic Illness Care in PHC organizations in Quebec:– 33%-41% across types of PHC organizations

« What are the obstacles or facilitators to the implementation of integrated models of prevention and management of chronic illnesses? »

Problem and question

(Source : Levesque, Feldmand et al. 2008)


• Interview/coding grid– Synthesis of CCM and WHO performance

framework components

• Literature review– 50 papers on implementation of integrated

models

• Experts consultation– 12 experts – semi structured interviews– Regional decision-maker, researchers, analysts

• Content analysis and coding

Research method


• Lack of information systems in clinical settings – Barriers to understanding service provision and to the

integration of clinical decision-support tools;

• Absence of an organizational body– responsible for establishing clinical guidelines and

continuum of care protocols;

• Payment models favouring acute care and unplanned services instead of chronic care;

Principal barriers


• Lack of public coverage of multidisciplinary services;– or mobilisation of professionals to primary care clinics

• Poorly organized primary care;– not benefiting from a structure enabling a proactive

approach to illness management

• Absence of an evaluation culture and tools to assess performance and feedback on performance towards quality improvement.

Principal barriers (2)


• Emergence of organizational models compatible with PHC group practice (Family Medicine Groups, Network Clinics);– Gradual improvement in clinical management capacities

• Progressive integration of health care system institutions and planned implementation of local health networks;– Possibility of contractual agreements on continuum of

care

Principal facilitators


• A well-developed community sector and a strong institutional basis – Local Community Health Centers;– Supporting the medical and professional network

• A well-developed public health sector having identified chronic illnesses as a priority in its services program.– Integration of health promotion and prevention in PHC

settings?

Principal facilitators (2)


Conclusion

• Low levels of implementation of CCM in Canada• Structural barriers should be removed in order to

improve chronic illness management– Payment methods, performance culture, PHC

organization, lack of computerization

• Recent opportunities emerging– New models of PHC, community-based services, system

integration

• Need to address system factors that can impede implementation of CCM


Institutional and financial support

Thank you!

CALASS 2006 Implementing Integrated Models of Prevention & Management of Chronic Illness Care:...

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