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How much do you know about chronic diseases?

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Background

Statistics indicate three chronic diseases have the greatest impact on the health of the people of the north and cannot be addressed in isolation due to the interdependency of factors causing each disease. The creation of a Northern Chronic Care Coalition (NCCC) is a means to address the many and varied needs of quality chronic care within the constraints of limited human resources and less than optimal community supports.

The primary focus or scope of the Coalition will be:

diabetes

cardiovascular disease (hypertension, heart disease, high cholesterol)

COPD (chronic obstructive pulmonary disease)

The NCCC, composed of health care providers and key community people, augments current services through the enhancement of planned, integrated chronic care by collaboratively developing, implementing and coordinating a northern chronic disease management strategy that addresses the most commonly occurring chronic diseases in the north.

The “Expanded Chronic Care Model” (Victoria J, Barr et al) will be used as a framework to structure the Coalition and the resulting integrated strategies for chronic care in the north. The Chronic Care Model spells out strategy components for both the Health System and for the Community.

The coalition is being developed in two phases:

Phase I

The Coalition focuses on the health system components of the Chronic Care Model including Elders, client representatives, and health practitioners from Northern Health Strategy (NHS) communities, agencies and jurisdictions. Particular attention is paid to self-management and personal skill development, delivery system design, decision support and information systems.

Phase II

Coalition membership expands to include broader community member representation. Phase II Coalition activities encompass the community components of the Expanded Chronic Care Model focusing on: strengthening community action, creating supportive environments and building healthy public policy.

Northern Health Strategy members continue to participate in the Health Quality Council Chronic Disease Management Collaborative. As well, they work collectively in a three-year initiative establishing a patient self-management program, “Living a Healthy life with Chronic Conditions.”

Activities

Sustain the Northern Chronic Disease Collaborative

  • Develop supportive structures (charter, resources, funding) to initiate and sustain the Coalition.
  • Determine representation on the Coalition from NHS jurisdictions.
  • Establish processes to enhance interdisciplinary communication across jurisdictions.
  • Acquire financial, human and capital resources to facilitate the functioning of the Coalition.

    • Support People Living With Chronic Conditions

  • Enhance community development processes to increase prevention and awareness activities.
  • Enhance self-management of chronic disease at the grassroots level.
  • Engage community input, feedback and support in developing chronic disease services.
  • Improve access to and equity of services.

    • Standardize Approaches to Chronic Disease Management (CDM)

  • Support the development of a shared client registry, with Information Technology support for the use of developing and monitoring services.
  • Coordinate of common chronic disease education across jurisdictions.
  • Facilitate common approaches to CDM across the North e.g. case management standards, flow-sheets, algorithms.
  • Share knowledge, expertise, and events.
  • Share knowledge and best practices amongst collaborative membership.
  • Coordinate of educational initiatives and events.
  • Establish links with other Chronic Disease initiatives, locally, provincially and nationally.

    • Monitoring Outcomes

  • Establish a process for ongoing evaluation of the Coalition and the impact on CDM in the North.
  • Determine sources of data for evaluation and identify gaps in information.
  • Establish indicators to monitor the success of CDM initiatives in the North, such as patient satisfaction, statistics of incidence and prevalence, and availability/access of services.
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