Preventing and Managing Chronic Disease

The full document, Preventing and Managing Chronic Disease : Ontario’s Framework, is available for download below.

A variety of chronic disease prevention and management success stories in Ontario are also available.

Ontario's Framework

In Ontario, as is the case in developed countries throughout the world, chronic diseases are the leading cause of death and disability. Almost 80% of Ontarians over the age of 45 have a chronic condition. Of those, approximately 70% suffer from two or more chronic conditions. (CCHS, 2003) Left untreated or managed poorly, chronic conditions can deteriorate and predispose individuals to other chronic conditions. In Ontario the economic burden of chronic disease is estimated to be 55% of total direct and indirect health costs.

The good news is that there is great potential to improve health outcomes and reduce the burden of chronic disease.

• An interdisciplinary, community-based Latino diabetes self-care clinic delivered with the participation of Latino health professionals licensed outside Ontario saw a 14% absolute reduction in blood glucose levels within one year (London InterCommunity Health Centre).
• A self-management education program for chronic obstructive pulmonary disease reduced hospital admissions by 40% and emergency room visits by 40%, and improved health related quality of life (reported by: Bourbeau J,et al. Arch Int Med 2003;163:585-91).
• A congestive heart failure discharge program reduced the number of hospital readmissions by 68% in the first nine months by coordinating care and educating clients and families (Group Health Centre, Sault Ste. Marie).
• By focusing on primary and ambulatory care, the Veterans Health Administration significantly decreased hospitalizations, leading to a reduction of acute operating beds from 52,000 to 19,000 over a seven year period and a drop of about 60% in the average daily inpatient population (Department of Veterans Affairs, Program Statistics April 2003).
• Kaiser Permanente adopted a series of systematic measures to address chronic disease, including a multidisciplinary steering group, physician champions, patient registries, reminders, outreach programs, and the empowerment of local clinicians. Over a ten year period it achieved:
• A heart disease mortality rate that is 30% lower than in other plans;
• A 15% decrease in death rates from congestive heart failure from 1996-2001;
• A smoking rate of 12% among plan members from northern California compared to 18% for the state as a whole (Kaiser Permanente).

Evidence from other jurisdictions and innovative practices within Ontario make it clear that what is needed is a fundamentally different way of addressing chronic disease – a systems approach to prevention and management that :

• Is centred on individuals, empowering them to play a greater role in managing their health or illness and to become an integral part of the care team;
• Incorporates prevention at every stage to keep people as healthy as possible for as long as possible;
• Mobilizes interdisciplinary, integrated care teams so that individuals get the right care from the right provider in the right setting at the right time;
• Supports proactive, continuing care with regular follow-up to ensure that care is coordinated and that individuals have help navigating through the system.

Although Ontario is making inroads, it can do much to improve its approach to chronic disease prevention and management. That is why the Ministry of Health and Long-term Care has developed a framework to guide the redesign of health care practices and systems to improve the prevention and management of chronic disease. The Framework is based on models that have been used successfully in other jurisdictions, including the U.S., U.K., Australia, New Zealand and parts of Europe, as well as in British Columbia, Alberta, Saskatchewan and Manitoba.

Ontario’s Chronic Disease Prevention and Management Framework identifies a cluster of interconnected and mutually dependent practice and system changes that have been found to be effective in preventing and managing chronic disease. It consists of the following components :

• Health Care Organizations that make systematic efforts to improve prevention and management of chronic disease;
• Delivery System Design that is focused on prevention and that improves access, continuity of care and flow through the system;
• Provider Decision Supports that integrate evidence-based guidelines into daily practice;
• Information Systems that enhance information for providers so they can provide quality care, that support individuals in managing their diseases, and that integrate services across the system;
• Personal Skills and Self-Management Supports that empower individuals to build skills for healthy living and coping with disease;
• Healthy Public Policies that improve individual and population health and address inequities;
• Supportive Environments that remove barriers to healthy living and promote safe, enjoyable living and working conditions;
• Community Action that encourages communities to increase control over issues affecting the health of their residents.

In addition to the Framework, the ministry has developed a CDPM (chronic disease prevention and management) Logic Model. The CDPM Logic Model is a visual representation of the CDPM Framework, showing how specific activities contribute to better health and system outcomes and, can be used to develop performance indicators. This tool, in conjunction with the Framework, is being used for chronic disease planning and evaluation by the Ministry of Health and Long-Term Care, the Ministry of Health Promotion, LHINs, health organizations and providers

The CDPM Logic Model is a visual representation of the CDPM Framework, showing how specific activities contribute to better health and system outcomes and, can be used to develop performance indicators. The Priority Setting Decision Tool provides two methodologies to compare the burden of illness of a number of chronic diseases and can be used to help set chronic disease priorities. The tool is primarily intended to provide a methodology for local adaptation, the data given should only be treated as examples.

The best research evidence indicates that the approach of the Framework will improve the health and functioning of chronically ill Ontarians and reduce the incidence of chronic disease in the province. People will receive quality care from the right provider in the right setting at the right time and their clinical outcomes and quality of life will be better. Health care providers will be able to provide higher quality care and they will experience greater job satisfaction.

The evidence also suggests that the approach uses health system resources more efficiently and avoids costs: emergency departments are used less, there are fewer hospitalizations, and less duplication of services. The Framework approach will lead to a system that mobilizes health care organizations, individuals and their families, and communities in the effective prevention and management of chronic disease.