Session: Community Based Chronic Care Services: A Planning and Implementation Model for Evidence Based Improvements at Community and Practice Settings


Back to Annual Meeting Page		American Public Health Association 133rd Annual Meeting & Exposition December 10-14, 2005 Philadelphia, PA

4116.0: Tuesday, December 13, 2005: 12:30 PM-2:00 PM

Oral

Community Based Chronic Care Services: A Planning and Implementation Model for Evidence Based Improvements at Community and Practice Settings

The Public Health Resource Group (PHRG), Eastern Maine Healthcare Systems and others in consultation with the World Health Organization (Health System Policies and Operations) have been developing and testing innovative approaches to planning and implementing evidenced based chronic care improvements. These approaches are being used and validated in different settings and countries. Grounded in WHO’s Innovative Care for Chronic Conditions (ICCC) framework and building blocks we has developed, tested and implemented a chronic care planning and implementation roadmap and system that identifies community chronic care needs and issues, employs best practice processes to implementing evidence based change and evaluates and monitors change with process and outcomes measures for practices and patients. There are several components that are key to this system including rapid assessment tools that a) identify population chronic care conditions for prioritizing need, b) assess community based resources for patient self management and their linkages to primary care providers, c) assess the status of community level policies for their contribution to chronic disease; d) determine the level of practice infrastructure and operational readiness for best practice improvements, e) evaluate practices in the management of chronic conditions to evidence based guidelines and care and, f) determine patient barriers to care. To date preliminary rapid assessment tools have been develop and tested for a, b, d, and e. Additional components include a change process adapted from the Institute for Healthcare Improvement’s (IHI) Breakthrough Collaborative Series, and a framework for monitoring and evaluating changes.

Learning Objectives: At the conclusion of the session, the participant will: 1. Have a clear understanding of the tools and processes that enable healthcare providers and communities to develop and implement chronic care plans for their populations. 2. Understand the necessary components for evidence-based improvements of chronic care at each level-communities, practice and patient. 3. Have an understanding of the methods and major evaluation findings to date in several projects where we have used this approach.

Organizer(s):

Ronald D. Deprez, PhD, MPH

Moderator(s):

Ronald D. Deprez, PhD, MPH

12:30 PM

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