Advancing the chronic care road map: a contemporary overview.
In an effort to assess and advance the community-based model of chronic care, we reviewed a contemporary spectrum of Canadian chronic disease management and prevention (CDMP) programs with a participatory audience of administrators, academics, professional and non-professional providers and patients. While many questions remain unanswered, several common characteristics of CDMP success were apparent. These included community-based partnerships with aligned goals; inter-professional and non-professional care, including patient self-management; measured and shared information on practices and outcomes; and visible leadership. Principal improvement opportunities identified were the enhanced engagement of all stakeholders; further efficacy evidence for team care; facile information systems, with clear rationales for data selection, access, communication and security; and increased education of, and resource support for, patients and caregivers. Two immediate actions were suggested. One was a broad and continuing communication plan highlighting CDMP issues and opportunities. The other was a standardized survey of team structures, interventions, measurements and communications in ongoing CDMP programs, with a causal analysis of their relation to outcomes. In the longer term, the key needs requiring action were more inter-professional education of health human resources and more practical information systems available to all stakeholders. Things can be better.
McGill University, Montreal, Quebec. sara.ahmed@mcgill.ca
Sara
S
Ahmed
Amede
A
Gogovor
Mylene
M
Kosseim
Lise
L
Poissant
Richard
R
Riopelle
Maureen
M
Simmonds
Marilyn
M
Krelenbaum
Terrence
T
Montague
D002170:Canada; D002908:Chronic Disease / Q000517:prevention & control / Q000628:therapy*; D003153:Community Health Services / Q000458:organization & administration; D019468:Disease Management; D006801:Humans; D017146:Models, Organizational; D015397:Program Evaluation