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Implementation and evolution of a regional chronic disease self-management program

  • Public Health Intervention
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Abstract

OBJECTIVE: 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.

PARTICIPANTS: Health service delivery organizations.

SETTING: The Champlain Local Health Integration Network (LHIN), a health district in Eastern Ontario.

INTERVENTION: 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.

OUTCOME: 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 actively host 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.

CONCLUSION: 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.

Résumé

OBJECTIF: Établir un programme communautaire global pour améliorer et soutenir l’appui à l’auto-prise en charge des personnes atteintes de maladies chroniques, en complément des stratégies d’appui à la modification du comportement élaborées dans les unités de santé.

PARTICIPANTS: Des organismes de prestation de services de santé.

LIEU: Le réseau local d’intégration des services de santé (RLISS) de Champlain, un district de santé de l’Est de l’Ontario.

INTERVENTION: Nous avons créé Vivre en santé Champlain (VSC), un organisme régional qui: assure la formation et la coordination de pairs animateurs selon le programme d’auto-prise en charge des maladies chroniques (programme CDSMP) de l’Université Stanford; offre aux dispensateurs de soins de santé de la formation axée sur les compétences et du mentorat sur les approches de modification du comportement; et aide les organismes à intégrer l’appui à l’auto-prise en charge dans leurs pratiques courantes. Nous nous sommes servis du cadre RE-AIM pour évaluer l’impact global du programme en explorant sa portée, son efficacité, son adoption, sa mise en œuvre et le maintien de ses effets.

RÉSULTATS: En tout, 232 séances CDSMP de Stanford (63 pendant et 169 après le projet pilote) ont été tenues dans 127 établissements situés dans 24 villes du RLISS de Champlain, soit un bassin d’environ 4 000 patients. Nous avons évalué l’efficacité du service au moyen d’examens continus des données probantes, d’un groupe de discussion et d’une étude d’utilisation avant et après le projet pilote. VSC a formé plus de 300 pairs bénévoles à offrir les séances CDSMP de Stanford; 98 de ces bénévoles offrent encore activement des ateliers. En outre, 1 327 dispensateurs ont été formés selon d’autres modèles d’appui à l’auto-prise en charge, comme le coaching santé et la technique d’entrevue motivationnelle. Au cours de la période de l’étude, VSC est passé d’un petit projet pilote à une initiative régionale bénéficiant d’un financement provincial durable, et la province en a fait un modèle pour la prestation de services semblables ailleurs en Ontario.

CONCLUSION: Un programme communautaire d’auto-prise en charge mené en partenariat avec les soins primaires peut être mis en œuvre efficacement et à grande échelle pour appuyer les patients vivant avec des maladies chroniques.

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Authors and Affiliations

  1. C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, 43 Bruyère Street, Annex E, Room 106, K1N 5C8

    Clare Liddy MD, MSc, Sharon Johnston MD, Kate Nash MSc & Rachel Davidson BScHK, CK, CSEP-CEP

  2. Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada

    Clare Liddy MD, MSc & Sharon Johnston MD

  3. Care of the Elderly Research Program, Bruyère Research Institute, Ottawa, ON, Canada

    Hannah Irving MSc

Authors
  1. Clare Liddy MD, MSc
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  2. Sharon Johnston MD
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  3. Kate Nash MSc
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  4. Hannah Irving MSc
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  5. Rachel Davidson BScHK, CK, CSEP-CEP
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Correspondence to Clare Liddy MD, MSc.

Additional information

Acknowledgements: The authors extend their thanks to Karen Patzer from the Champlain Local Health Integration Network in Ottawa and Debbie McGregor, Executive Director, Bruyère Academic Family Health Team, Ottawa. We also thank Justin Joschko for his assistance in preparing the manuscript for resubmission.

Conflict of Interest: None to declare.

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Liddy, C., Johnston, S., Nash, K. et al. Implementation and evolution of a regional chronic disease self-management program. Can J Public Health 107, e194–e201 (2016). https://doi.org/10.17269/cjph.107.5126

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