title: Implementation and evolution of a regional chronic disease self-management program.
abstract: To establish a comprehensive, community-based program to improve and sustain self-management support for individuals with chronic diseases and complement office-based strategies to support behaviour change.
  
  
  
  Health service delivery organizations.
  
  
  
  The Champlain Local Health Integration Network (LHIN), a health district in Eastern Ontario.
  
  
  
  We created Living Healthy Champlain (LHC), a regional organization providing peer leader training and coordination for the group Stanford Chronic Disease Self-Management Program (CDSMP); skills training and mentorship in behaviour change approaches for health care providers; and support to organizations to integrate self-management support into routine practice. We used the RE-AIM framework to evaluate the overall program's impact by exploring its reach, effectiveness, adoption, implementation and maintenance.
  
  
  
  A total of 232 Stanford CDSMP sessions (63 during the pilot project and 169 post-pilot) have been held at 127 locations in 24 cities across the Champlain LHIN, reaching approximately 4,000 patients. The effectiveness of the service was established through ongoing evidence reviews, a focus group and a pre-post utilization study of the pilot. LHC trained over 300 peer volunteers to provide the Stanford CDSMP sessions, 98 of whom continue to activelyhost workshops. An additional 1,327 providers have been trained in other models of self-management support, such as Health Coaching and Motivational Interviewing. Over the study period, LHC grew from a small pilot project to a regional initiative with sustainable provincial funding and was adopted by the province as a model for similar service delivery across Ontario.
  
  
  
  A community-based self-management program working in partnership with primary care can be effectively and broadly implemented in support of patients living with chronic conditions.
authors.affiliation: C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, 43 Bruyère Street, Annex E, Room 106, K1N 5C8. cliddy@bruyere.org.|Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada. cliddy@bruyere.org.
authors.forename: Clare
authors.initials: C
authors.lastname: Liddy
authors.affiliation: C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, 43 Bruyère Street, Annex E, Room 106, K1N 5C8.|Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Sharon
authors.initials: S
authors.lastname: Johnston
authors.affiliation: C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, 43 Bruyère Street, Annex E, Room 106, K1N 5C8.
authors.forename: Kate
authors.initials: K
authors.lastname: Nash
authors.affiliation: Care of the Elderly Research Program, Bruyère Research Institute, Ottawa, ON, Canada.
authors.forename: Hannah
authors.initials: H
authors.lastname: Irving
authors.affiliation: C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, 43 Bruyère Street, Annex E, Room 106, K1N 5C8.
authors.forename: Rachel
authors.initials: R
authors.lastname: Davidson
mesh_terms: D000368:Aged; D002908:Chronic Disease / Q000523:psychology / Q000628:therapy*; D003153:Community Health Services / Q000458:organization & administration*; D005260:Female; D017144:Focus Groups; D006282:Health Personnel / Q000523:psychology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D010865:Pilot Projects; D011320:Primary Health Care / Q000458:organization & administration; D011369:Professional-Patient Relations; D016730:Program Development; D015397:Program Evaluation; D012648:Self Care / Q000523:psychology; D012944:Social Support