Living Well With A Chronic Condition

Overview

CDM Strategy, Calgary Health Region, Alberta Health Services

The elements of the Region’s CDM strategy and how the chronic care model has been implemented are described below.

Nurse Support in Primary Care: Community-based nurses are partnered with family physicians to provide support in the management of people with chronic conditions through a client-centred approach to case management, referral to appropriate services and disease management according to clinical practice guidelines.

Living Well with a Chronic Condition Program: A community-based exercise, education and self-management program for people with a range of chronic conditions is provided by the Region and operates from 15 accessible community locations. This program is described in more detail in the following section.

Programs for Diverse Populations: There is multicultural aspect to the above CDM programs to reduce access barriers experienced by the two largest cultural groups in Calgary - the Chinese and Indo-Asian populations.

Complex Chronic Care: An inter-disciplinary clinic is available to care for patients with multiple chronic conditions to reduce their high admission rate. High intensity, high frequency users of the acute care system are identified and referred to the clinic where internists, specialized nurses and a multi-disciplinary team manage these patients with complex conditions.

Access to Specialist Expertise in Primary Care: Specialty clinic expertise is provided to family physicians in their offices by Certified Diabetes Educators (Diabetes, Hypertension, and Cholesterol Centre staff) and Certified Respiratory Educators (Calgary COPD and Asthma Program staff). Care and role algorithms are developed in partnership with specialty clinics.

Academic Detailing: Pharmacists provide practical, evidence-based information and tools to support clinical decision-making for family physicians and other community healthcare providers through one-on-one or small group physician visits.

Information System: An electronic chronic disease management information system is available to: support communication between health care providers; enable providers to monitor the progression of disease; provide prompts to consider further monitoring or interventions according to practice guidelines; and assist in a coordinated care approach by sharing information and supporting workflow.

Evaluation: Performance measurement and quality improvement are being integrated into all CDM programs. Key performance indicators are collected and analyzed to assess the quality and effectiveness of CDM programs and to provide a standard from which incremental change can be measured.

CDM Dissemination:

• In partnership with the World Health Organization and the Public Health Agency of Canada, the Region hosts a bi-annual international CDM conference to provide a forum for knowledge exchange and discussion on a global level. Information for the 2009 conference will be posted at http://www.cdmcalgary.ca/.

• Sponsored by Alberta Health and Wellness, the Region leads a province-wide dissemination project build capacity and develop new competencies in CDM. These include both disease-specific proficiencies and broad skills in facilitation techniques, care planning, motivational interviewing and self-management.

• The Region hosts Information Days monthly in response to increasing requests for program visits and information. Interested persons can obtain a registration form from the CDM website www.calgaryhealthregion.ca/cdm.

Living Well with a Chronic Condition Program

Program Overview

The Living Well with a Chronic Condition Program (Living Well) serves clients in Calgary and surrounding areas who have chronic, long-term health conditions including, but not limited to, diabetes, hypertension, chronic obstructive pulmonary disease, asthma, dyslipidemia, chronic pain, osteoporosis, arthritis, obesity, cognitive impairment, congestive heart failure, or breast cancer. The program is designed to enable clients with a chronic disease to better manage their condition and to live the best possible life with a long-term illness.

Living Well has three major pillars: disease-specific education, supervised exercise and self-management (Row Your Own Boat). Clients can take any one part or all parts of the program and in any order, but it is recommend that clients take the whole program to best manage their chronic condition. In addition nutrition and social work counseling are offered.

The underlying principles of Living Well follow the chronic care model. Self-management is integrated into all aspects of the program including self-referral, client-driven education, self-monitoring and modification of exercise, action-planning, and specific self-management workshops. Programs are delivered in accessible, community-based locations with one-stop-shopping. Community partnerships provide options for clients following completion of the program and client follow-up promotes sustainability.

Living Well is offered at 15 sites throughout Calgary and the surrounding rural communities of Cochrane, Airdrie, Okotoks and Vulcan. Programs are offered in community facilities such as recreation complexes and community centres in early mornings, during the day, and in early evenings.

Living Well is delivered by an inter-disciplinary team including registered dietitians, social workers, kinesiologists, physiotherapists, occupational therapists, respiratory therapists, community fitness leaders and administrative support staff.

Potential clients access Living Well through self-referral, physician referral, or referral by other health care providers. The client must have a chronic condition and be able to function in a group environment to be eligible to participate. If the client requires assistance in a group it is acceptable to be accompanied by a caregiver. Referrals for all locations are received and processed by a central call centre – 403-9HEALTH.

All programs are offered free of charge, except the Exercise Program which is $80 for the 8-week core program. Subsidy is available and approximately one third of clients are subsidized.

Education Program

The goal of the Living Well education program is to provide a supportive environment that allows individuals living with chronic conditions to access the tools necessary to maximize the benefits of lifestyle change and to foster behaviour change by providing them with information on their disease, available resources, management strategies and treatment options. A client-centred approach is adopted whereby the facilitator tailors the program to the needs of the class participants. Classes are offered in English, and many are offered in Cantonese, Hindi and Gujarati.

Living Well education classes are available in both disease specific and general lifestyle content areas. Class format is adapted based on the requirements of the specific chronic disease and is facilitated by either experts from specialty clinic partners or Living Well staff. The role of Living Well in these partnerships is to provide the infrastructure to operate the classes (space, promotion, booking), and the role of the partners is to develop the content and provide the expert to facilitate the sessions. Partners include the Diabetes, Hypertension and Cholesterol Centre, Chronic Pain Centre, Breast Health, Mental Health, Osteoporosis Clinic, Arthritis Society and Alzheimer Society. These partners can now deliver education to clients in more accessible community settings. This has expanded the reach of specialty clinics, reduced the wait for education and enabled specialty clinics to focus their expertise on seeing the more complex/high risk patients.

The complete Living Well education offering and description of each session is available at http://www.calgaryhealthregion.ca/cdm. A summary of topics includes:

• Arthritis 101
• BP Basics
• Carbohydrate Counting
• Cholesterol & Trigs
• COPD – Breathing Matters
• Coping Emotionally with a Chronic Illness
• Dementia: Developing a Positive Perspective
• Diabetes Essentials
• Diabetes Refresher
• Pre-Diabetes – Reducing Your Risk
• Explaining Pain
• Food & Mood

• Glycemic Index
• Life After Gestational Diabetes
• Lifestyles
• Navigating the Web
• OT Tips
• Osteoporosis & Bone Health
• Pain Self Management
• Tasting 101
• Thriving After Breast Cancer
• Vitamins & Minerals
• Your Marvelous Brain

Exercise Program

On the basis of a recent review of randomized controlled trials, there is accumulating evidence that, for patients with chronic disease, exercise increases functional capacity and reduces the risks for development of disease complications.^[4] A major unmet need in the Region was the availability of exercise programs for people with a variety of chronic conditions despite the overwhelming evidence of the health benefits of exercise. Living Well was developed, in part, to address this need. The Living Well supervised exercise program is a proactive approach to care that focuses on keeping a person as healthy as possible through regular physical activity.

Intake into the Exercise Program is in two steps. First is a group session held at three sites, where clients receive an orientation to Living Well, have basic metrics collected and intake questionnaires reviewed, and are triaged with respect to: requirement for an exercise test prior to participation; and the appropriate exercise program. Over ten group sessions are scheduled each month to facilitate easy access. The second step is to meet one-to-one with a health care provider for an in-depth assessment of physical abilities, limitations and needs.

Currently the Living Well program offers four types of exercise programs:

• Easy Going Classes: for individuals with significant limitations to physical activity who require close supervision, and are unable to complete 10 minutes of physical activity without stopping. Exercise focuses on improving mobility, balance, musculoskeletal strength/endurance, and flexibility. Classes are run by a physical therapist and/or kinesiologist. Occupational and respiratory therapists are available on a consult basis.
• Get Going Classes: for individuals with some limitations to physical activity who require a moderate level of physiologic monitoring, and are unable to complete 10 minutes of physical activity without stopping. The exercise focuses primarily on improving aerobic capacity/endurance, muscular strength/endurance, flexibility, and balance. Classes are run by a CHR kinesiologist, respiratory therapist, and/or physical therapist. Occupational therapists are available on a consult basis.
• Keep Going Classes: for individuals with few limitations to exercise that require minimal supervision, are able to complete 10 minutes of physical activity without stopping, and are not significantly limited by symptoms during exercise. The exercise focuses primarily on improving aerobic capacity/endurance, muscular strength/endurance, flexibility, and balance. A CHR kinesiologist runs this class. Physical therapists, respiratory therapists, and occupational therapists are available on a consult basis.
• On the Go: for individuals who are unable to attend the site-based classes and are safe to exercise in an unmonitored environment. Clients receive the same orientation, assessment and follow-up as our site-based programs and have five one-to-one sessions with a kinesiologist, either by phone or face-to-face, over an eight week period.

These programs are not disease-specific, and clients with a range of chronic conditions participate. Classes are offered two to three times per week for eight weeks with each class being 60-90 minutes in duration. In addition to Region staff, support is provided by a fitness leader from the community site. These same fitness leaders offer maintenance programs at their sites for Living Well graduates. The maintenance programs are administered by the site, and clients pay a discounted membership or per class fee to participate.

To assess client progress and program effectiveness, measures are collected at program intake, program exit, and six and twelve months post-program. The following measures are collected at each time point: blood pressure, body weight, BMI, waist circumference, six-minute walk test distance, sit-to-stand test cycles, and, in the Easy Going groups, Timed Up and Go (TUG) balance measure. Questionnaires assessing quality of life, physical activity, emotional health, fruit and vegetable intake, and self-efficacy are also administered at each assessment time point.

Self Management – Row Your Own Boat

The Row Your Own Boat program is a six-week workshop that teaches clients the skills to manage the day-to-day challenges of living with a chronic condition. It is modeled on the Stanford Chronic Disease Self-Management Program.^[5] Workshops are not disease-specific and each class includes clients with a variety of chronic conditions. Row Your Own Boat leaders are trained according to Stanford’s specifications. Over 50 leaders have been trained to date, approximately two-thirds of whom are volunteer lay-leaders, all of whom have a chronic condition.

Subjects covered in the workshops include: goal setting and problem solving; managing difficult emotions such as frustration and fear; coping with pain and fatigue; exercise and nutrition guidelines; appropriate medication usage; effective communication strategies; making informed treatment decisions; symptom management; and developing a positive partnership with health-care professionals.

Counseling

Living Well registered dietitians facilitate many of the group education sessions, and also partner with the CDM nurses to counsel clients in the primary care setting. They also accept referrals for clients who require nutrition counseling for a chronic illness and for whom a group class is not available (e.g. Celiac disease). Living Well social workers facilitate some of our group sessions such as Row Your Boat, support the CDM nurses in primary care, and counsel Living Well clients. Their role is to assist clients in accessing services, provide emotional support, liaise with community agencies on behalf of clients, and advocacy.

Quality Improvement - Outcomes

There are three essential components for continued progress in CDM: research, performance measurement, and quality improvement. This section will focus on performance measurement and the outcomes of a specific subset of the CDM population, Living Well program clients. Routine collection of data and the provision of feedback to care providers have been shown to produce improvements in the process of care ^[6] and patient outcomes ^[7]. A sampling of the outcomes analyzed to date for the Living Well program is reported here.

Data on a cohort of 2220 clients who participated in any of the Living Well programs and who had complete registration data in the Information System were included in this analysis. Data was compared from baseline to one-year post-program. Given that multiple data sources were utilized and to avoid impact of seasonal effects, a baseline measure was the average of all measures taken during the period 11 months prior to program onset and 1 month after program onset, and the 1-year outcome was the average of all measures taken between 6 and 18 months post-program.

Clients were an average of 57 years old, and 60% were female. Plotting of disease trajectory, defined as the number of bed-days per 1000 patients, indicates that the Living Well population was declining in health in the year prior to program onset. (see Figure 1) Main chronic conditions, in order of prevalence, were diabetes, hypertension, dyslipidemia, chronic pain, obesity and COPD.

A sampling of disease-specific outcomes shows significant improvements in disease indicators one year after program participation. If higher risk clients are analyzed separately, the absolute improvement in disease indicators is even greater. (See Table 1)

Health care utilization was assessed in this cohort by examining emergency department (ED) visits and in-patient admissions per 1000 patients. Results reveal a significant 14.3% reduction in ED visits one year following program participation, and a 63.7% reduction in higher risk clients (> 2 ED visits in the year prior to participation).(see Figure 2) There was no significant change from baseline to one year in inpatient admissions for the entire cohort. However, if only the high risk clients were analyzed ((> 2 admissions in the year prior to participation) then a 75.4% reduction was observed at one year. (see Figure 3)

Next Steps

The next five years look to expand and refine existing strategies and core programming such as the Living Well program and CDM nursing in primary care. Plans also include the development and implementation of new strategies to address the prevention of chronic diseases by targeting high-risk populations such as those with several predisposing risk factors. Targeted interventions for diverse and special populations such as Vietnamese, Filipino, Aboriginal, the homeless and shelter residents are also planned. Systematic evaluation and quality improvement will be embedded into all CDM programs.