Improve early detection, intervention, and outcomes for people with chronic diseases, specifically heart and lung disease

0
70

Improve early detection, intervention, and outcomes for people with chronic diseases, specifically heart and lung disease

0 Commentaires

Admissions per 100 HF patients and Admissions per 100 COPD patients measure the rate (per 100 cohort members) of inpatient admissions for people identified as being in the HF or COPD cohort, respectively. Hospitalizations for ACSCs measures the numeric rate (per 10,000) of hospitalizations for health conditions that may have been prevented or managed by appropriate primary health care.

One way to improve the quality of health care for people with HF, COPD, or other ACSCs is by providing appropriate, high-quality preventative services in the community and/or primary care setting. These indicators help track the outcome of services that people do or do not receive. Although there can be several factors outside the direct control of the health care system that result in hospitalization, this data can be used to provide insight on past performance, or to help identify where there are unmet community health care needs that would benefit from improvement interventions.

Approximately 1 in 4 adults over the age of 30 will be living with a major illness in 2040, requiring significant hospital care; this is an increase from approximately 1 in 8 individuals in 2002.¹ These increases may disproportionately impact the individuals who are most affected by the social determinants of health.

The planning and programming of chronic disease prevention and management continue to evolve in alignment with Ontario Health priorities and needs within the sector. Key areas of focus will be for OHTs to implement chronic disease prevention and management models rooted in primary care and community care settings within OHTs, targeting patients with many risk factors and/or with chronic and complex conditions, to ensure strong connections between upstream and downstream elements of the pathway.

Key Resources

¹Rosella LC, Buajitti E, Daniel I, Alexander M, Brown A. Projected patterns of illness in Ontario [Internet]. Toronto: Dalla Lana School of Public Health; 2024 [cited 11 Nov 2024]. Available from: https://www.oha.com/Documents/externalresources/Projected%20patterns%20of%20illness%20in%20Ontario.pdf

Changer les idées

Collaborate with partners on early identification of needs and upstream care activities

Use tools for early risk identification and preventative management
Health care providers can leverage tools and resources, including academic detailing, from the Centre for Effective Practice:
COPD
Type 2 Diabetes
Preventative Care for Older People
Managing Patients with Heart Failure in Primary Care
Point-of-care testing (including glucometers, HbA1c, microalbumin, lipid panels, cardiac panels, and cluster testing as clinically appropriate)

Provide education and training to health system planners, providers, patients, families, and care partners on best practices for care of patients with chronic diseases

HF
Minimal requirements and key clinical services for heart failure programs within a spoke-hub-node model of care
Heart Failure quality standard pathway
Integrated Clinical Pathways CoP
Heart and Stroke Foundation – Heart failure resources
Canadian Cardiovascular Society – Management of HF
HeartLife Foundation
COPD
COPD quality standard pathway
COPD quality standard implementation toolkit
Academic detailing for primary care on the topic of COPD
Diabetes
Diabetes Canada – Clinical Practice Guidelines
Public Health Ontario – Diabetes resources
Registered Nurses’ Association of Ontario (RNAO) Best Practice Guidelines – Diabetic foot ulcers: Prevention, assessment and management
International Working Group on the Diabetic Foot – Guidelines and resources Wounds Canada – Best Practice Recommendations for the Prevention and Management of Diabetic Foot Ulcers
Palliative care
Ontario Palliative Care Network – Palliative Care Health Services Delivery Framework
Ontario Palliative Care Network – Tools to Support Earlier Identification for Palliative Care
Ontario Palliative Care Network – Palliative Care Toolkit
RISE brief 18: Resources to support population-health management for people who could benefit from a palliative approach to care
RISE brief 27: Ontario Palliative Care Network and how it can support OHTs as a health-system partner
General preventative care
Support individuals working in health care or on health care teams to become prevention specialists through training in motivational interviewing, chronic disease self-management (choices and changes training may be offered in each former Local Health Integration Network (LHIN) through their self-management programs), smoking cessation counselling (English only), physical literacy, nutrition, food insecurity (English only), diabetes management training, and health promotion
Chronic disease self-management and preventative care education for patients and care partners
Regional Chronic Disease Self-Management Programs

Develop and implement a collaborative model for service delivery to patients with chronic diseases

Leverage the quality standards and best practice guidelines listed above
Create shared care models with multisector partnerships, informed by primary care leadership
CorHealth Ontario – Integrating Heart Failure Care (provincial road map and implementation support toolkit)
CorHealth Ontario – Lower-Limb Preservation Strategy
Ensure that the pathways are co-designed with patients who have lived experience
Ensure alignment with Ontario Health’s Social Determinants of Health Framework and Equity, Inclusion, Diversity, and Anti-Racism Framework. Integrate principles from these frameworks into the pathway to address health disparities and promote equity
Social Determinants of Health: The Canadian Facts, 2nd Edition
National Collaborating Centre for Determinants of Health – Glossary of Essential Health Equity Terms
Join the Integrated Clinical Pathway communities of practice (HF, COPD, Lower-Limb Preservation) to learn, develop skills, and access resources that can help you plan and implement clinical pathways for patients with chronic diseases

Leverage digital and virtual solutions to improve processes and workflow

Use digital health solutions and technology to support integration, documentation, and communication. Plan for integration and coordination across different sectors and care settings for the lifetime of a patient’s condition
Ontario Health’s Digital Health Programs
- Includes Health811, eConsult and eReferral, Ontario Laboratories Information System (OLIS), ClinicalViewer, Health Report Manager (HRM), Ontario Telemedicine Network (OTN) Hub, and solutions for virtual visits
Provincially funded virtual care programs (remote care management for HF and COPD)
Evidence2Practice Ontario provides tools for HF, COPD, diabetes, and other conditions for use in acute care and primary care to assist with screening, diagnosis, decision-making, quality interventions, monitoring, connecting patients to self-management supports, and patient conversations (English only)
Project ECHO Skin and Wound features live online sessions, de-identified patient cases, and case discussions. Health care providers and specialists learn from each other, acquire knowledge and skills, increase competency, and build a strong community of practice. Project ECHO follows the hub-and-spoke model, in which an interprofessional specialist resource team forms the hub, and participants (supported by a community of practice) are the spokes