AHC Teams

A total of 11 improvement teams were struck across the four Atlantic provinces, each with region-specific improvement aims, team members and improvements selected by their local leadership. Team improvements supported patients and families with diabetes, chronic obstructive pulmonary disease (COPD), mental health issues or multi-morbidity issues; some were based in acute settings while others took place in the community. Detailed descriptions of each initiative are below, while illustrated storyboards are available here.

Newfoundland & Labrador

Central Health

Improving processes of care for patients living with chronic obstructive pulmonary disease

Central Health’s improvement project focused on developing and implementing a COPD program that focused on health promotion, education and the uptake of clinical practice guidelines across the local system. The province’s failing grade (F) from the 2005 Canadian Lung Association’s National Report Card on Chronic Obstructive Pulmonary Disease (COPD), along with the 2008 CIHI reports on COPD’s admission and readmission rates, emphasized the need for educating healthcare providers in the prevention, diagnosis and management of COPD. The team has been successful in creating an outreach program for patients living with advanced COPD and their families, targeting home-based support including self-management education, action plan development, psychosocial support and, where appropriate, advance care planning.

They have also redesigned the former asthma outpatient clinic into the Respiratory Care Centre, which uses a 9-month pathway combining onsite medical management with education and self-management support for the mild – moderate COPD population. They have seen 60 patients in a two-month span since opening and continue to progress as one of 19 teams in CFHI’s INSPIRED Approaches to COPD QI Collaborative (2014-15).

Eastern Health

Supporting integrated management and clinical care for people with diabetes

As part of a broader Chronic Disease Management (CDM) initiative centered on diabetes care for the province of Newfoundland, Eastern Health identified the need to strengthen collaboration at transition points to create seamless approaches to diabetes care. Pulling away from a system designed around the provider, the Improvement Project team identified the need to develop a seamless approach to diabetes care that focuses on individual patients needs in a timely manner.

With information gathered through a regional patient survey, the team plans to utilize the information gathered to identify priorities for the regional diabetes program and develop a plan to implement and evaluate improvements in type 2 diabetes education and support for patient self-management. A series of regional meetings with front-line providers, as well as the establishment of an advisory group are key steps to Eastern Health’s success in supporting integrated diabetes care through this work.

Western Health

Improving self-management support within regional diabetes teams

Enhancing services for clients with diabetes has been one of three strategic goals at Western Health with an increase in the prevalence of diabetes among the population. The Improving Health: My Way Chronic Disease Self-Management Program was introduced on a regional basis to support client self-management, however there was still an opportunity to improve self-management support to strengthen the overall approach to self-management for clients with diabetes in the western region.

Using the Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS) tool pre- and post-evaluative processes, the team has been able to demonstrate improvements across all categories from baseline to follow-up, including provider education and patient input. The team reported a 100% compliance of a depression screening tool for people living with type 2 diabetes and provided staff with a new compliments and complaints policy for soliciting patient feedback. A community of practice has been also established for diabetes providers with resources, educational tools and a blog for providers to stay connected and discuss opportunities and challenges to providing self-management support.

Labrador-Grenfell Health

Self-management approaches to diabetes care

Aboriginal leaders from the Nunatsiavut Government (Inuit), NunatKavut (Inuit-Metis), and Innu First Nations identified diabetes as one of the top health concerns for their communities. This project aimed to improve the effectiveness of primary care and community interventions for diabetes and related complications among high-risk Indigenous populations by integrating lifestyle and activity-based clinical interventions with community supports to improve the control of diabetes and reduce the incidence and rates of complication. Designed and managed by Memorial University’s Faculty of Medicine and Labrador Grenfell Health in collaboration with the Nunatsiavut Government’s Department of Health and Social Development, NunatuKavut, and the Sheshatshiu Innu First Nation, this partnership aligns an interdisciplinary primary healthcare team with appropriate community organizations to co-develop and pursue innovations in healthcare delivery.

Clinic visits have been redesigned to include a multidisciplinary team of healthcare providers and community elders to work with diabetes patients. A walking group intervention has been established and continues to see success in patients in self-managing their care through increased activity-based interventions.

Labrador-Grenfell Health

Community-centered mental health care and suicide prevention in central and northern Labrador

To better understand local experiences of suicide and improve mental health services, Labrador-Grenfell Health partnered with the Innu Nation, the Nunatsiavut Government, and Memorial University to develop contextual knowledge about suicide in central and northern Labrador and translate this into enhanced mental health care. This work has involved ongoing dialogue and research with community- and hospital-based service providers, elders, youth, and leaders.

The team has established a database on attempted and deaths by suicide in nine Labrador communities and have begun analyzing the data with the goals of documenting the risk factors and health service use patterns associated with suicide, understanding the mental health care experiences of patients with a history of suicidality and translating local knowledge and data into health systems improvements. In addition, clinical staff with Labrador-Grenfell Health began supplementing this research by documenting the number of clients region-wide presenting with suicidal ideation and/or attempts.

Labrador-Grenfell Health

Improving diabetes through a regional approach

In response to the regional goal of strengthening capacity in priority areas to improve health and wellness outcomes, the project focuses on the diabetes population and developing regional health status standard data set, developing a Diabetes Prevention and Management Plan and implementing selected recommendations of the plan.

As of early 2015, the team has established an advisory committee for project support and regular updates related to the project are provided to staff on a monthly basis through their newsletter. They have also established a diabetes registry through MediTech, have selected five indicators that can be measured for diabetic outcomes during the project and made considerable progress in standardizing practices and policies.

New Brunswick

Vitalité Health Network

Primary healthcare reform: implementing interdisciplinary models of care

Following the release of a provincial framework for primary healthcare in New Brunswick, Vitalité Health Network has been working to develop and implement new models of care that align with the provincial strategies for improving primary healthcare outcomes. Specific strategies for improved primary care have focused on integrating services in line with community health needs, and engaging patients in healthcare decision-making through a patient-centered model of care. Interdisciplinary health teams have been developed and engaged at the core of the Improvement Project, favouring improvements that span the continuum of health and encourage participation from the community to achieve positive health outcomes.

The team continues to push this work forward with a strategic coordination committee to ensure sustainability of the initiative. The work plan aims to improve primary care related to timely access to care, system navigation and service integration/cross-sector coordination.

PEER 126

Implementation of a community based young adult mental health engagement and education initiative – PEER 126

In June 2012, a psychosocial rehabilitation program within a recovery-based model for young adults with serious mental illness was established in Saint John entitled Peers Engaged in Education and Recovery (PEER 126) through collaborative efforts with the Medavie Health Foundation. The program is staffed with multidisciplinary teams that work under a population health approach to care and recovery, with the goal to improve, restore, promote and maintain the emotional health and well-being of young adults 16-29 years of age.

Through data gathered on utilization of services, the program has shown a decrease use of healthcare services by participants and report making progress toward goals, e.g. friendships, activities, and skills for active employment. Client surveys focusing on levels of concern in life areas pre- and post-PEER 126 showed youth self-report improvements in thirteen of the fourteen areas. The team continues to carry out evaluative work examining engagement of PEER 126 members to better understand retention in terms of strengths, limitations, challenges and opportunities.

Nova Scotia

Nova Scotia Health Authority – Central Zone (formerly Capital Health)

Assessing the feasibility of implementing an integrated chronic disease prevention and management strategy at Nova Scotia Health Authority - Central Zone

Nova Scotia Health Authority - Central Zone has many successful chronic disease prevention and management (CDPM) programs and services. These CDPM programs were created and spear-headed by experienced clinical leaders and researchers who identified needs, care gaps and leveraged the available funding to create optimal and enhanced clinical programs and initiatives. However, the zone needed a strategic framework to guide the integration and coordination of service delivery across the spectrum of chronic illness.

Through two phases – (1) review of current CDPM programs and (2) implementation of pilot CDPM improvements for organization-wide adoption to sustain system transformation, the care team successfully reduced wait times to care for people living with multimorbidity and complex conditions to two months in 2014 with no wait times for care anticipated in 2015. Increased patient engagement and satisfaction are also outcomes of this innovative initiative. In addition, successful transformations and implementation have resulted in resource efficiencies without increase in costs. Patients have shown significant improvements in functional health following Integrated Chronic Care Service (ICCS) intervention. The methodology will be applied to other chronic disease management areas in Capital Health and the province.


Learn more about this work addressing complex care for CDPM patients in Nova Scotia, as shared during the November 5th, 2014 CDPM Symposium held by Nova Scotia Health Authority – Central Zone

Prince Edward Island

Health PEI

Reducing preventable hospitalizations for ambulatory care sensitive conditions (ACSCs)

PEI’s hospitalization rates for ACSCs are consistently higher than the national average due to a number of factors related to health system design. Many of the reasons for higher rates in hospital readmissions relate to poor discharge planning and management, as well as breakdowns in communication between patients and providers and at-home clinical support. Inadequate discharge planning and premature discharges, lack of patient education on care maintenance, and poor primary care follow-up are key factors influencing readmissions that would otherwise be preventable with adequate and effective follow-ups and self-management support tools at the primary care level.

By consulting with patients and allied healthcare providers and physicians to identify the systematic problems, Health PEI identified chronic obstructive pulmonary disease (COPD) as a key priority area for enhancing support for patients to help prevent those readmissions that are potentially avoidable. Focus has been placed on improving the transitions between patients’ experience with acute and primary care services to enhance quality of services and improve health outcomes. The team continues to progress as one of 19 teams in CFHI’s INSPIRED Approaches to COPD Collaborative (2014-15).

Health PEI

Spreading a “minimal intervention” approach to care

Through a rigorous system improvement approach, Health PEI is working to develop new skills for working with patients as partners in their own health. The team has integrated self-management support (SMS) training for more than 111 targeted healthcare providers, providing strategies and skills to be less prescriptive when speaking with patients and more focused on client-centered approaches that promote self-efficacy. Post-training surveys have showed higher provider satisfaction in the training and tools and increased confidence in SMS ability in working with patients. Training has taken place with providers represented from areas of home care, public health and primary care, targeting program areas with keen early adopters. Plans are now in place to develop a certification/re-certification program for peer facilitators, a refresher/booster course for clinicians, and a community of practice/support network for practicing facilitators and clinicians.