Guysborough Antigonish Strait Health Authority (NS)

  • Jane Newlands, Manager, Primary Health Care and Seniors' Health, Guysborough Antigonish Strait Health Authority, Antigonish, Nova Scotia 

Transition to Interdisciplinary Collaborative Care Teams to Support an Integrated Chronic Disease Management Strategy in Rural Nova Scotia

There is a lack of access to collaborative teams in primary care settings for residents of rural northeastern Nova Scotia (the region served by the Guysborough Antigonish Strait Health Authority). This lack of access is contributing to an increased prevalence of chronic conditions within the district health authority. The resulting burden of chronic disease, while challenging for the individuals and families living with these conditions, is also affecting acute care service delivery. The Guysborough Antigonish Strait Health Authority (GASHA), in response to this need, has made improving health and quality of life of its residents and enhanced access to appropriate services two of its five strategic directions for the next five years (2011-2016).

The aim of this intervention project was twofold: 1) to develop a long-term plan for addressing chronic disease management and prevention in an integrated, sustainable manner and 2) to implement collaborative teams in multiple settings throughout the district. The purpose of these teams is to support collaborative care planning in primary care and meet community-based cardiovascular/chronic disease rehabilitation needs for individuals living with chronic conditions or at high risk for development of these conditions.

Using the Expanded Chronic Care Model as a guide, the EXTRA fellow (and steering committee) created a long-term logic model (expected to coincide with the course of the District Health Authority’s strategic plan). GASHA senior leadership has approved the model in principle with a request to establish a prioritized action plan to accompany the model and identify timelines, roles and responsibilities.

By disinvesting in a program providing duplication in care within the district and transferring the services it provided to other existing and appropriate providers, GASHA was able to mobilize human and financial resources to support chronic disease management and prevention initiatives. The organization was able to introduce the role of the collaborative chronic disease management nurse into five family practices within the district (established based on the Calgary model of chronic disease management and consistent with the patient medical home concept). As well, the district was able to change the delivery model of their successful cardiovascular/chronic disease rehabilitation program to make it sustainable and efficient by securing ongoing funding for the pilot project and establishing the team as mentors for community-based local teams to provide this service rather than continuing with the former outreach model. GASHA also established a system to provide training and mentorship in the principles of self-management support and the use of motivational interviewing for providers working with individuals with chronic conditions. GASHA integrated the new services and teams into existing family practices and communities and with the intention of providing more comprehensive, coordinated care planning and rehabilitation for individuals living with chronic conditions.

Through the intervention project, GASHA successfully introduced these new service delivery models, demonstrating positive outcomes for clients and positive responses from providers with respect to new ways of providing care. The success was largely attributable to the dedication and leadership of front-line staff involved in the transition. These changes will serve as models for implementation of interdisciplinary teams in other communities within the District Health Authority as part of provincially approved/funded initiatives and may be considered models for development of collaborative practice and innovative ways to approach provision of equitable care in rural settings. Note that GASHA will conduct further evaluations and monitoring of the interventions to determine system impacts of changes introduced through the EXTRA program and make adjustments to care delivery models as required.