Anticipatory programming that addresses these impacts offers an opportunity to address the course of the chronic disease and to assist individuals to be informed, self managers of their condition.

The changing dynamics of health care emerging from Ontario Ministry of Health’s transformation agenda has influenced the ways in which partners work together to provide a continuum of care. This change facilitates a broad but consequential perspective to chronic disease prevention and management. No one person, no one sector can address the multitude of factors and impacts of chronic disease. A collaborative approach engaging partners is the only solution.

The Grey Bruce Integrated Health Coalition (GBIHC) CDPM Framework Tool Kit project is the result of emerging local initiatives in the hospital sector, community, and in primary health care. The Ontario CDPM framework is referred to as the context within which existing and developing services should function. The Southwest Local Health Integration Network has established a Priority Action Team targeting chronic disease prevention and management as a strategic priority.

The challenge for healthcare, social service and community organizations is applying the framework in the real world.

But how does one take the framework from a conceptual level to a useful resource that drives and supports the design of services, activities and initiatives?

But how does one take the framework from a conceptual level to a useful resource that drives and supports the design of services, activities and initiatives? The GBIHC mandated the development of a tool kit. The kit walks users through understanding the framework, to developing programs that maximizes use of existing resources, and reflects an integrated care approach for individuals living with chronic illness.

Why is using the kit useful to your organization or group?

It:

• Avoids possible parallel initiatives and maximizes the use of existing resources for care delivery.
• Ensures that key stakeholders are involved in planning/redesigning services and programs.
• Clarifies and makes best use of the complementary roles/services provided by stakeholders.
• Helps build service systems that are person and community centred and reflect the continuum of care from prevention and health promotion through to palliation.

Many health care and health promotion organizations as well as communities and individuals play a role in chronic disease prevention and management (CDPM) therefore planning a CDPM initiative needs to be explicit and inclusive. In planning a CDPM initiative:

• How do you proceed?
• What is the purpose and scope of the initiative?
• Who are the recipients of the initiatives?
• Who are the partners and stakeholders?
• How does the initiative fit in the current, local system of CDPM?
• Are the objectives and deliverables identified?
• How will outcomes be measured?;

The Grey Bruce Integrated Health Coalition CPDM Framework tool kit is a step- by-step approach to planning CDPM initiative, strategy or program. The tool kit takes a two fold workflow approach.

The first section of the workflow is concerned with understanding the Framework. The three steps in this process are:

• Review the Ontario Chronic Disease Prevention and Management Framework diagram
• Review the Element Definitions in CDPM
• Review the Logic Model

The second section is concerned with applying the framework

• Complete Program Feasibility Checklist
• Complete the Logic Model for Program Planning
• Complete the “Initiating a Health Program Checklist”
• Revise Program (Logic Model) Plan as required

Two programs piloted the tool kit – the Grey Bruce District Stroke Centre and the PRIISME Project for Diabetes. The two programs identified similar lessons from using the tool kit:

• A good exercise. Explicitly explains our relations, roles and responsibilities.
• Health Care organization and the individual component of the model are easy to complete
• Identifying outputs succinctly is challenging
• Community component is challenging due to the need to be inclusive
• Identify time frames of outcomes – used 1 – 5 years with stroke
• Outcomes will depend on disease process or the goal of the initiative
• For stroke dividing Health Care Organizations into Education, Evidence Base Practice etc was helpful
• Need to identify partners and relationships
• Need a glossary of terms e.g. International Classification of Function – can add this to the Definitions in the Model
• Outcomes section forces you to indicate how you would measure the outcome.
• Model helps to identify where we needed to strengthen relationships
• Self Management – messages or skills sets are the same with different group

Each group found the application of the tool to be helpful in applying the Ontario Framework to their specific context.

Summary

The tool kit is meant to guide programs through the Ontario Chronic Disease Framework in a systematic and comprehensive manner.

The tool kit is a knowledge translation tool about the Ontario CDPM Framework as well as a guide to applying the framework.

The tool kit is a knowledge translation tool about the Ontario CDPM Framework as well as a guide to applying the framework. It eases the use of the framework by using logic models and checklists to help the user explicitly map the process for their program. The tool kit is designed with all the information you need readily accessible.