Nova Scotia Health Authority adds value to care for patients living with multiple chronic conditions

by Nadine Morris | Feb 23, 2016
Working with the Canadian Foundation for Healthcare Improvement through the AHC, NSHA examined service processes to identify wasteful practices from the patient’s point of view.


This story is part of a collection featuring improvements from the Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC).

The Challenge

Chronic disease is on the rise across the Atlantic provinces, and the number of patients suffering from multiple chronic conditions – or multimorbidity – is also rising. The Nova Scotia Health Authority (NSHA - formerly Capital Health) has many successful chronic disease prevention and management (CDPM) services for patients and their families to help manage chronic conditions. The problem, however, is often that these services have lacked integration and coordination across the spectrum of illness.

To help ensure continuity of care across programs and services, and to enhance communication, providers from four service areas came together to redesign patient care. The Integrated Chronic Care Service (ICCS), the Diabetes Management Centre, the Community Health Team and the INSPIRED chronic obstructive pulmonary disease (COPD) Outreach ProgramTM examined opportunities to redesign a process to eliminate wasteful practices and optimize practices that enhance the patient care experience.

The Solution

Working with the Canadian Foundation for Healthcare Improvement through the AHC, NSHA examined service processes to identify wasteful practices from the patient’s point of view. Patient input, in turn, informed redesign of care processes to better address the needs of those living with multiple chronic conditions. The NSHA team gathered evidence, feedback from key stakeholders (patients and providers) and data from administrative systems (on current care processes and utilization). They used the working together tool to establish relationships among participating teams. The team developed and used a modified value-stream mapping (VSM) approach – a lean technique – aligned with the components of the Chronic Care Model (CCM). They applied this approach with the guidance of a systems engineer to draw out the gaps and opportunities in each of the four CDPM services, as well as identify common process aspects across all four areas at intake, program delivery, transition and follow-up.

“[This initiative] has provided a platform for our team to better engage our patients in identifying and implementing improvements that meets their many needs related to complex chronic conditions. Already, the early impact of this initiative has led to significant improvements in our wait times, improvements in our clinical information systems, improving access to our patients, improving engagement of patients in our care delivery, bringing a better focus on our self-management processes and identifying gaps and opportunities for future changes.”

“Patient input informed redesign of care processes to better address the needs of those living with multiple chronic conditions.”

The Results

Through a two-phased approach – (1) review of current CDPM programs and (2) implementation of pilot CDPM improvements for organization-wide adoption to sustain system transformation – system-level changes have been integrated across CDPM services at NSHA. These changes have informed improved patient access to care, satisfaction and functional status all while containing costs and creating efficiencies. The process improvements include:

  • A common clinical intake form
  • A standardized electronic progress note, outlining the patient care pathway (patient reviews, analysis of findings and modification of treatments)
  • Booking and registration codes that align with the patient’s journey (vs. the provider or disease/condition) within the system and support care for multimorbidities, creating timely and relevant care
  • A core set of validated instruments to serve as common measures of three key components of chronic disease management: self-management, functional health management and quality of life
  • Redesigned care pathways to reduce duplication for individuals with multimorbidities;
  • Core competency-based learning and training modules for providers such as basics for chronic disease management, behavior change interventions and strategies, health literacy, functional health, clinical information systems, decision support processes.

By offering telehealth, group visits, and telephone outreach, the team was able to reduce wait times in one service area (ICCS) from 13 months in 2012 to two months in 2014 and no waits in 2015.

This work has ultimately informed the creation of NSHA’s comprehensive CDPM Corridor©, a three-pronged approach to better care for chronic conditions: (1) Service redesign; (2) Common elements for CDPM (such as common outcomes, clinical intake processes, standards for health literacy and core competency modules); and (3) A hub of supports to guide the review and development of processes to better support care for individuals living with chronic conditions. Additionally, information technology was also revamped to better support data collection and provide patient information across all care providers, increasing care coordination across service areas.

The Spread

The project team hosted a provincial symposium in November 2014 in partnership with CFHI and with Dr. Edward Wagner – one of the pioneers of the extended Chronic Care Model – as the keynote speaker to improve spread and share the outcomes with other interested groups across the province. They have also recently published results in the International Journal of Health Policy and Management and Healthcare Quarterly. The project team was also accepted into CFHI’s Partnering with Patients and Families for Quality Improvement collaborative, which began in September 2014. The team received the 2015 3M Quality Award for their “My Care My Voice” initiative, which was one of four service areas involved in the work through the Atlantic Healthcare Collaboration. The team also visited healthcare providers in Denmark, Finland and Sweden to conduct workshops about integrated care models for complex conditions and multi-morbidities in October 2015.

Lynn EdwardsLynn Edwards
Senior Director, Primary Health Care and Chronic Disease
Nova Scotia Health Authority




SampalliTara Sampalli
Assistant Director, Quality and Research in Primary Healthcare
Nova Scotia Health