A Patient-Centred Redesign Framework to Support System-Level Process Changes for Multimorbidities and Chronic Conditions.

Recent trends show an increase in the prevalence and costs associated with managing individuals with multimorbidities. Enabling better care for these individuals requires system-level changes such as the shift from a focus on a single disease or single service to multimorbidities and integrated systems of care. In this paper, a novel patient-centred redesign framework that was developed to support system-level process changes in four service areas has been discussed. The novelty of this framework is that it is embedded in patient perspectives and in the chronic care model as the theoretical foundation. The aims of this paper are to present an application of the framework in the context of four chronic disease prevention and management services, and to discuss early results from the pilot initiative along with an overview of the spread opportunities for this initiative.

A novel community-based model to enhance health promotion, risk factor management and chronic disease prevention.

Chronic disease is a highly expensive but preventable problem to the healthcare system. Evidence suggests that impacting modifiable behaviours and risk management factors in the areas of physical inactivity, unhealthy diet, stress and obesity can alleviate the burden of chronic disease problem to a large extent. Despite this recognition, the challenge is embedding these recognized priorities into the community and in primary care in a sustainable and meaningful manner. Primary Health Care in Capital Health responded to this challenge by developing and implementing a free, interprofessional and community-based service, namely, the Community Health Teams (CHTs), that offers health and wellness, risk factor management, wellness navigation and behaviour-based programming. In this paper, the development and implementation of the CHTs are discussed. Preliminary outcomes for the model are significant and promising. Formal and large-scale studies are planned to validate these outcomes with additional research rigour.

Development and evaluation of a "working together" framework and a tool kit to enhance inter-organizational relationships in healthcare.

Healthcare is in a constant state of change and evolution driven by a multitude of complex factors and interactions. Consequently, organizations, teams and individuals in healthcare have to habitually realign their working relationships. Furthermore, research has shown that "working together" relationships fail in the absence of a defined framework. In this research, a novel framework and a tool kit for working together have been developed and evaluated. The framework has a formal process to articulate the intended purpose/outcome, clearly align the type of working relationship with the purpose and identify the barriers and facilitators to working relationships in healthcare.