title: A Patient-Centred Redesign Framework to Support System-Level Process Changes for Multimorbidities and Chronic Conditions.
abstract: Recent trends show an increase in the prevalence and costs associated with managing individuals with multimorbidities. Enabling better care for these individuals requires system-level changes such as the shift from a focus on a single disease or single service to multimorbidities and integrated systems of care. In this paper, a novel patient-centred redesign framework that was developed to support system-level process changes in four service areas has been discussed. The novelty of this framework is that it is embedded in patient perspectives and in the chronic care model as the theoretical foundation. The aims of this paper are to present an application of the framework in the context of four chronic disease prevention and management services, and to discuss early results from the pilot initiative along with an overview of the spread opportunities for this initiative.
authors.affiliation: Assistant director of quality, research and knowledge management in primary healthcare, Nova Scotia Health Authority, Halifax, Nova Scotia. She is also assistant professor in the Department of Medical Informatics at Dalhousie University, in Halifax, Nova Scotia.
authors.forename: Tara
authors.initials: T
authors.lastname: Sampalli
authors.affiliation: Senior Director responsible for primary healthcare and chronic disease management at Nova Scotia Health Authority, Halifax, Nova Scotia (previously known as Capital District Health Authority).
authors.forename: Lynn
authors.initials: L
authors.lastname: Edwards
authors.affiliation: project lead in primary health care at Nova Scotia Health Authority, Halifax, Nova Scotia.
authors.forename: Erin
authors.initials: E
authors.lastname: Christian
authors.affiliation: Health services manager in primary healthcare at Nova Scotia Health Authority, Halifax, Nova Scotia(previously know as Capital District Health Authority).
authors.forename: Graeme
authors.initials: G
authors.lastname: Kohler
authors.affiliation: Executive Training for Research Application (EXTRA) Fellow, is a health services manager in primary healthcare at Nova Scotia Health Authority, in Halifax, Nova Scotia.
authors.forename: Lisa
authors.initials: L
authors.lastname: Bedford
authors.affiliation: Program Coordinator for The INSPIRED COPD Outreach ProgramTM at Nova Scotia Health Authority, Halifax, Nova Scotia.
authors.forename: Jillian
authors.initials: J
authors.lastname: Demmons
authors.affiliation: Senior Director, Collaboration for Innovation and Improvement at the Canadian Foundation for Healthcare Improvement, Canada.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Verma
authors.affiliation: Family physician and chief of the Department of Family Practice at Nova Scotia Health Authority, Halifax, Nova Scotia.
authors.forename: Rick
authors.initials: R
authors.lastname: Gibson
authors.affiliation: Executive Training for Research Application (EXTRA) fellow, is a health services manager in primary healthcare at Nova Scotia Health Authority, Halifax, Nova Scotia (previously known as Capital District Health Authority).
authors.forename: Shannon Ryan
authors.initials: SR
authors.lastname: Carson
mesh_terms: D002170:Canada; D002908:Chronic Disease / Q000517:prevention & control / Q000628:therapy*; D015897:Comorbidity; D003695:Delivery of Health Care / Q000458:organization & administration; D006801:Humans; D017146:Models, Organizational; D009936:Organizational Innovation; D018802:Patient-Centered Care / Q000458:organization & administration*; D058996:Quality Improvement / Q000458:organization & administration