Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 3
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
4 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 5
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
6 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
• 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:
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 7
• 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.
8 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 9
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.
10 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 11
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
12 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 13
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
14 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 15
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.
16 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 17
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/
wk
1. G
oals
: Som
ethi
ng y
ou W
AN
T to
do:
2. D
escr
ibe
H
ow: _
____
____
____
____
____
____
____
_
W
here
: ___
____
____
____
____
____
____
__
W
hat:
___
____
____
___
Fre
quen
cy: _
____
____
___
W
hen:
___
____
____
____
____
____
____
____
____
__
3. B
arri
ers:
___
____
____
____
____
____
____
____
____
__
4. P
lans
to
over
com
e ba
rrie
rs: _
____
____
____
____
____
5. C
onvi
ctio
n __
____
__ &
Con
fiden
ce _
____
___r
atin
gs
(0
- 10
)
6. F
ollo
w-U
p: _
____
____
____
____
____
____
____
____
__
1. G
oals
: Som
ethi
ng y
ou W
AN
T to
do:
2. D
escr
ibe
H
ow: _
____
____
____
____
____
____
____
_
W
here
: ___
____
____
____
____
____
____
__
W
hat:
___
____
____
___
Fre
quen
cy: _
____
____
___
W
hen:
___
____
____
____
____
____
____
____
____
__
3. B
arri
ers:
___
____
____
____
____
____
____
____
____
__
4. P
lans
to
over
com
e ba
rrie
rs: _
____
____
____
____
____
5. C
onvi
ctio
n __
____
__ &
Con
fiden
ce _
____
___r
atin
gs
(0
- 10
)
6. F
ollo
w-U
p: _
____
____
____
____
____
____
____
____
__
Beg
in e
xerc
isin
g
Wal
king
Aro
und
the
bloc
k
2 tim
es
afte
r di
nner
have
to c
lean
up;
bad
wea
ther
8
Act
ion
Plan
Act
ion
Plan
(Ex
amp
le)
ask
kids
to h
elp;
get
rai
n ge
ar
7
next
vis
it –
2 m
onth
s
18 Best Advice – Chronic Care Management in a Patient's Medical Home junE 2016
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.
junE 2016 Best Advice – Chronic Care Management in a Patient's Medical Home 19
References
1.TheCollegeofFamilyPhysiciansofCanada.A Vision for Canada: Family Practice – The Patient’s Medical Home.Mississauga,ON:TheCollegeofFamilyPhysiciansofCanada;2011.Availablefrom:www.cfpc.ca/A_Vision_for_Canada/. Accessed 2015 Oct 5.
2.NasmithL,BallemP,BaxterR,BergmanH,Colin-ThoméD,HerbertC,etal.Transforming Care for Canadians with Chronic Health Conditions: Put People First, Expect the Best; Manage for Results.Ottawa,ON,Canada:CanadianAcademyofHealthSciences;2010.
3.BodenheimerT,WagnerEH,GrumbachK.ImprovingPrimaryCareforPatientsWithChronicIllness.JAMA.2002;288:1775-1779.doi:10.1001/jama.288.14.1775
4.ElmslieK.Against the Growing Burden of Disease.PublicHealthAgencyofCanada[presentation].Availablefrom:www.ccgh-csih.ca/assets/Elmslie.pdf. Accessed2015Sept25.
5. Canadian Institute for Health Information. Seniors and the Health Care System: What Is the Impact of Multiple Chronic Conditions.CIHI;2011.Availablefrom: https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf.Accessed2016February29.
6.PublicHealthAgencyofCanada.TheHealthofCanadianChildren.In:Report: The State of Public Health in Canada, 2009.Ottawa,ON:PHAC;2009.Available from: www.phac-aspc.gc.ca/cphorsphc-respcacsp/2009/fr-rc/cphorsphc-respcacsp06-eng.php. Accessed 2016 Feb 29.
7.OsbornR,MouldsD,SquiresD,DotyMM,AndersonC.Internationalsurveyofolderadultsfindsshortcomingsinaccess,coordination,andpatient-centeredcare. Health Aff (Millwood).2014;33(12):2247-55.doi:10.1377/hlthaff.2014.0947
8. Canadian Diabetes Association. Diabetes in Canada.Toronto,ON:CanadianDiabetesAssociation;2015.Availablefrom:www.diabetes.ca/getmedia/513a0f6c-b1c9-4e56-a77c-6a492bf7350f/diabetes-charter-backgrounder-national-english.pdf.aspx. Accessed 2015 Nov 30.
9.PublicHealthAgencyofCanada.Report from the Canadian Chronic Disease Surveillance System: Hypertension in Canada, 2010.Ottawa,ON:PHAC;2010.Available from: www.phac-aspc.gc.ca/cd-mc/cvd-mcv/ccdss-snsmc-2010/2-2-eng.php. Accessed 2015 Nov 30.
10.StatisticsCanada.Arthiritis.Availablefrom:www.statcan.gc.ca/pub/82-229-x/2009001/status/art-eng.htm. Accessed 2015 Nov 30.
11. Grumbach K. Chronic illness, comorbidities, and the need for medical generalism. Ann Fam Med.2003;1(1):4-7.
12.PublicHealthAgencyofCanada.ChronicDiseaseRiskFactors.Availablefrom:www.phac-aspc.gc.ca/cd-mc/risk_factors-facteurs_risque-eng.php. Accessed2015Sept29.
13.StatisticsCanada.Bodycompositionofadults,2012to2013.Availablefrom:www.statcan.gc.ca/pub/82-625-x/2014001/article/14104-eng.htm. Accessed 2015 Nov 30.
14.Hanna,A.Ontario Medical Association Policy on Chronic Disease Management.Toronto,ON:OntarioMedicalAssociation;2009.Availablefrom: www.oma.org/Resources/Documents/2009ChronicDiseaseManagement.pdf. Accessed 2015 Oct 2.
15.WilsonB.Sick and Tired: The Compromised Health of Social Assistance Recipients and the Working Poor In Ontario.Toronto,ON:CommunitySocialPlanningCouncilofToronto(CSPC-T),UniversityofToronto’sSocialAssistanceintheNewEconomyProject(SANE),andtheWellesleyInstitute;2009.Available from: http://www.wellesleyinstitute.com/wp-content/uploads/2011/11/sickandtiredfinal.pdf. Accessed 2015 Oct 16.
16.WorldHealthOrganization.Chronicdiseasesandhealthpromotion.Availablefrom:www.who.int/chp/chronic_disease_report/media/Factsheet1.pdf?ua=1.Accessed2016May.
17.WorldHealthOrganization.FacingtheFacts:TheImpactofChronicDiseaseinCanada.Availablefrom:www.who.int/chp/chronic_disease_report/media/CANADA.pdf. Accessed 2015 Oct 19.
18.HollanderMJ,KadlecH,HamdiR,TessaroA.IncreasingvalueformoneyintheCanadianhealthcaresystem:newfindingsonthecontributionofprimarycare services. Healthc Q.2009;12(4):32-44.
19.DinhTT,BounajmF.ImprovingPrimaryHealthCareThroughCollaboration.Briefing 3: Measuring the Missed Opportunity.Ottawa,ON:ConferenceBoardofCanada;2013.
20.StevensGD,ShiL,VaneC,NieX,PetersAL.Primarycaremedicalhomeexperienceandhealth-relatedqualityoflifeamongadultmedicaidpatientswithtype2diabetes.J Gen Intern Medicine.2015;30(2):161-168.doi:10.1007/s11606-014-3033-4
21.HealthCouncilofCanada.BeyondtheBasics:TheImportanceofPatient-ProviderInteractionsinChronicIllnessCare.In:Canadian Health Care Matters Bulletin 3.Toronto,ON:HealthCouncilofCanada;2010.Availablefrom:www.healthcouncilcanada.ca/tree/2.16-HCC_CHCM_FINAL_ENGLISH.pdf. Accessed 2015 Oct 2.
22.WagnerEH,ColemanK,ReidR,PhillipsK,SugarmanJR.Guiding transformation: how medical practices can become patient-centered medical homes. Washington,DC:TheCommonwealthFund;2012.Availablefrom:www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2012/Feb/1582_Wagner_guiding_transformation_patientcentered_med_home_v2.pdf. Accessed 2016 Feb 25.
23.WagnerEH.ChronicDiseaseManagement:WhatWillItTakeToImproveCareforChronicIllness?Eff Clin Pract.1998;1(1):2-4.
24.BarrVJ,RobinsonS,Marin-LinkB,UnderhillL,DottsA,RavensdaleD,etal.TheexpandedChronicCareModel:anintegrationofconceptsandstrategiesfrom population health promotion and the Chronic Care Model. Hosp Q.2003;7(1):73-82.
25.MinistryofHealthandLong-TermCare.Preventing and Managing Chronic Disease: Ontario’s Framework.Toronto,ON:MinistryofHealthandLong-TermCare;2007.Availablefrom:www.health.gov.on.ca/en/pro/programs/cdpm/pdf/framework_full.pdf.Accessed2015Sep17.
26.WozniakL,SoprovichA,MundtC,JohnsonJA,JohnsonST.ContextualizingtheProvenEffectivenessofaLifestyleInterventionforType2DiabetesinPrimaryCare:AQualitativeAssessmentBasedontheRE-AIMFramework.Can J Diabetes.2015;39(Suppl3):S92-9.doi:10.1016/j.jcjd.2015.05.003
27.HouleJ,BeaulieuMD,ChiassonJL,LespéranceF,CôtéJ,StrycharI,etal.GlycaemiccontrolandselfmanagementbehavioursinType2diabetes:resultsfroma1-yearlongitudinalcohortstudy.Diabet Med.2015;32(9):1247-54.doi:10.1111/dme.12686.
28.HouleJ,Lauzier-JobinF,BeaulieuMD,MeunierS,CoulombeS,CôtéJ,etal.Socioeconomicstatusandglycemiccontrolinadultpatientswithtype2diabetes:amediationanalysis.BMJ Open Diabetes Res Care.2016;4(1):e000184.doi:10.1136/bmjdrc-2015-000184.
29.ColemanMT,NewtonKS.Supportingself-managementinpatientswithchronicillness.Am Fam Physician.2005;72(8):1503-10.
30.KohHK,BrachC,HarrisLM,ParchmanML.Aproposed‘healthliteratecaremodel’wouldconstituteasystemsapproachtoimprovingpatients’engagementin care. Health Aff (Millwood).2013;32(2):357-67.doi:10.1377/hlthaff.2012.1205.
31.VancouverIslandHealthAuthority.PortAlberniIHN.CommunicationsandPublicRelations;2013.Availablefrom:www.viha.ca/phc_cdm/phc_cdm_prog/ihn/pa_ihn.htm. Accessed 2015 Dec 1.
32.RobinsonJH,CallisterLC,BerryJA,DearingKA.Patient-centeredcareandadherence:definitionsandapplicationstoimproveoutcomes.J Am Acad Nurse Pract.2008;20(12):600-7.doi:10.1111/j.1745-7599.2008.00360.x
33.VermeireE,HearnshawH,VanRoyenP,DenekensJ.Patientadherencetotreatment:threedecadesofresearch.Acomprehensivereview.J Clin Pharm Ther. 2001;26(5):331-42.
34.LissDT,ReidRJ,GrembowskiD,RutterCM,RossTR,FishmanPA.Changesinofficevisituseassociatedwithelectronicmessagingandtelephoneencountersamong patients with diabetes in the PCMH. Ann Fam Med.2014;12(4):338-43.doi:10.1370/afm.1642.
35.CollegeofFamilyPhysiciansofCanada.Timely Access to Appointments in Family Practice.Mississauga,ON:TheCollegeofFamilyPhysiciansofCanada;2012.BestAdvice.Availablefrom:http://patientsmedicalhome.ca/files/uploads/PMH_Best_Advice_Enhancing_Timely_Access.pdf.Accessed2015Sept30.
36.AgencyforHealthcareResearchandQuality.ToolkitforImplementingtheChronicCareModelinanAcademicEnvironment.October2014.Availablefrom:www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/index.html.Accessed2016May.
37.MurrayM,TantauC.Same-dayappointments:explodingtheaccessparadigm.Fam Pract Manag.2000;7(8):45-50.
38.SteinbauerJR,KorellK,ErdinJ,SpannSJ.Implementingopen-accessschedulinginanacademicpractice.Fam Pract Manag.2006;13(3):59-64.
39.CollegeofFamilyPhysiciansofCanada.Patient Rostering in Family Practice.Mississauga,ON:CFPC;2012.BestAdvice.Availablefrom:patientsmedicalhome.ca/files/uploads/PMH_Best_Advice_Rostering.pdf. Accessed 2015 Oct 19.
40.GlasgowRE,DavisCL,FunnellMM,BeckA.Implementingpracticalinterventionstosupportchronicillnessself-management.Jt Comm J Qual Saf. 2003;29(11):563-74.
41.DinhTT,BounajmF.ImprovingPrimaryHealthCareThroughCollaboration.Briefing3:MeasuringtheMissedOpportunity.Ottawa,ON:ConferenceBoardofCanada;2013.
42.AlbertaHealth.PrimaryCareNetworks.Availablefrom:www.health.alberta.ca/services/primary-care-networks.html. Accessed 2015 Dec 2.
43.R.A.MalatestandAssociatesLtd.PrimaryCareInitiativeEvaluation:SummaryReport.Edmonton,AB:PrimaryCareNetworks;2011.Availablefrom: www.pcnevolution.ca/SiteCollectionDocuments/PCNe%20Overview/malatest-PHC-PrimaryCareInitiative-Evaluation2011.pdf. Accessed 2015 Dec 3.
44.ZelmerJ,HagensS.AdvancingprimarycareuseofelectronicmedicalrecordsinCanada.Health Reform Observer – Observatoire des Réformes de Santé. 2014;2(3):Article2.doi:10.13162/hro-ors.v2i3.1214.
45.PricewaterhouseCoopers.The emerging benefits of electronic medical record use in community-based care.Toronto,ON:PwC;2013.Availablefrom: www.pwc.com/ca/en/industries/healthcare/publications/electronic-medical-record-use-community-based-care.html.Accessed2015Sept18.
46.TaylorR,BowerA,GirosiF,BigelowJ,FonkychK,HillestadR.Promotinghealthinformationtechnology:isthereacaseformore-aggressivegovernmentaction?Health Aff (Millwood).2005;24(5):1234-45.
47.LauF,KuziemskyC,PriceM,GardnerJ.Areviewonsystematicreviewsofhealthinformationsystemstudies.J Am Med Inform Assoc.2010;17(6):637-45.doi:10.1136/jamia.2010.004838.
48.DahrougeS,HoggWE,RussellG,TunaM,GeneauR,MuldoonLK,etal.Impactofremunerationandorganizationalfactorsoncompletingpreventivemanoeuvresinprimarycarepractices.CMAJ.2012;184(2):E135-43.doi:10.1503/cmaj.110407
49.LapointeL,HughesJ,SimkusR,LortieM,SancheS,LawS.The Population Health Management Challenge Final Report.Montreal,QC:St.Mary’sHospital,MEdbASEResearch,McGillUniversity;2012.Availablefrom:www.smhc.qc.ca/ignitionweb/data/media_centre_files/597/Infoway_Challenge_Final_Report_January2011[1].pdf.Accessed2015Sept23.
50. Canadian Public Health Association. A tool for strengthening chronic disease prevention and management through dialogue, planning, and assessment: the tool, worksheets and resources.Ottawa,ON:CPHA;2008.Availablefrom:www.cpha.ca/uploads/portals/cd/worksheets_e.pdf. Accessed 2015 Oct 2.
51. National Center for Chronic Disease Prevention and Health Promotion. The Four Domains of Chronic Disease Prevention – Working Toward Healthy People in Healthy Communities.Atlanta,GA:CentersforDiseaseControlandPrevention;2015.Availablefrom:www.cdc.gov/chronicdisease/pdf/four-domains- factsheet-2015.pdf.Accessed2015Sept22.