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A Collaborative Approach to a Chronic Care Problem:
Evaluative Results from the Atlantic Healthcare Collaboration

Le service d'interprétation simultanée est offert pour cette séance.


The Atlantic Healthcare Collaboration (AHC) for Innovation and Improvement in Chronic Disease is a prime illustration of the expression: “If you want to go far, go together.” At a time when health systems are striving to provide patient- and family-centred chronic care that meets people where they are, the Atlantic provinces came together to improve healthcare for people living with chronic disease through the AHC.

Facing escalating rates of chronic disease and rising healthcare costs, Atlantic regional health authorities – with endorsement from provincial departments of health – worked in partnership with the Canadian Foundation for Healthcare Improvement (CFHI) to make care more patient- and family-centred and sustainable. By creating a network of care teams that designed, implemented and evaluated chronic care improvements (focusing on diabetes, mental health, chronic obstructive pulmonary disease and multimorbidity), the AHC also provided organizations with the capacity to create disruptive change.

Join CFHI for a three-part webinar series where AHC improvement teams will share, through case examples, the process undertaken by clinicians and managers to shift from ‘usual’ care to good chronic illness care. Evaluative results from both the team and collaborative level will also be profiled, highlighting lessons learned from undertaking a cross-regional quality improvement collaborative.

Learning Objectives:

This series will feature results from four AHC teams that designed, implemented and evaluated improvement initaitives as well as highlight the evaluative approach taken to capture lessons learned and key results from the broader AHC collaborative. The series will: 

  • Demonstrate solutions for making the shift from disease-oriented care to patient- and family-centered care that meet people where they are
  • Profile the experience of teams scaling their improvement projects and spreading them across delivery systems
  • Assess strategies for motivating the clinical front-line to make disruptive change to improve chronic care for patients and families
  • Share key evaluative findings and approaches from both the team and collaborative level

Sessions in the series:

Lessons from, Western Health (NL), Horizon Health Network (NB) and Nova Scotia Health Authority

Held November 25, 2015

On November 25, join CFHI and improvement teams from Horizon Health Network (NB) and Nova Scotia Health Authority (formerly Capital Health) during an interactive session that will provide participants with:

  • Case examples that articulate the process these organizations undertook to design, implement and evaluate improvement interventions
  • Strategies that improvement teams are using to sustain and spread their work across regions
  • Lessons learned and considerations for distinguishing good chronic illness care from usual care and working to close the quality gap to make best practices common across regions and provinces
  • Mechanisms for developing and implementing a patient-centred framework for evaluating current services to inform system-level redesign for improved patient care


Jennifer HenneburyJennifer Hennebury (Western Health), is the Regional Chronic Disease Prevention and Management Manager for Diabetes Services. Jennifer received a degree in Biochemistry from Memorial University with a major in Dietetics. For 4 years she worked as a registered dietitian in various diabetes clinics throughout Newfoundland and then became certified as a Diabetes Educator (CDE). Jennifer is finishing her Masters in Population Health through Memorial University in December 2015. Jennifer was a member of the CFHI project team for Western Health in her previous role as the regional self-management coordinator. In her new management role, Jennifer assumes the lead for sustaining and expanding self-management within local diabetes teams in Western Health.

Patti-DarlingAnnette Harland (PEER 126), is the Area Manager for Addiction and Mental Health Services in Charlotte County and Child and Youth Services in Saint John including PEER 126 and Early Psychosis. Annette received a Bachelor of Social Work degree from St. Thomas University anda Master of Social Work from Dalhousie University. She has been in a senior management role within the Addiction and Mental Health Program for the past 14 years and prior to that worked in the clinical front line for 15 years. Annette has been involved in the development of Addiction and Mental Health Services across the Saint John area. For the past four years she has provided leadership in the implementation of Integrated Service Delivery for Children, Youth and Families in Charlotte County, the development of PEER 126 and is a member of the Provincial Centre of Excellence Committee. Annette is passionate about furthering opportunities to improve addiction and mental health services.

Annette-HarlandPatti Darling is the Clinical Liason for PEER 126 and counsels children and youth for Community Mental Health Services in Saint John, NB. Patti spent the first 18 years of her career with Horizon Health working as a Recreation Therapist in geriatrics, veterans’ care and tertiary mental health. In 2009, Patti was afforded an opportunity to assist in the development of an inter-departmental, residential treatment program and acted in the capacity of Clinical Coordinator for four years. This experiences lead her back to school where she received a M.Ed. in Counselling from the University of New Brunswick. She is currently working towards certification in Play Therapy and Theraplay. Patti is committed to the importance of recovery based services and developing alternative means of providing community mental health programs.

Lynn EdwardsLynn Edwards (NSHA), BScN,PDt.,MHSA,Extra Fellow, is the Senior Director for Primary Health Care and Chronic Disease Management at the Nova Scotia Health Authority. With over twenty five years of varied and progressive leadership experience, Lynn is a strong and active participant in shaping the landscape of the health care system in Nova Scotia. She holds a bachelor of science (nutrition), a master of health services administration, is a Canadian Foundation for Healthcare Improvement extra fellow, and is well suited to build on the exceptional work underway in primary health care and chronic disease management that is taking place across the province. Most recently the health services director of primary health care and the district department of family practice at Capital Health, Lynn has also held leadership roles in health delivery and research within the Department of Health and Wellness in primary health care and as the director of acute and tertiary care. She has practiced as a clinical dietitian in rural Nova Scotia in a variety of inter-professional collaborative team settings and served on national and international boards. Reporting to Tricia Cochrane, vice-president, integrated health services - primary health care and population health, Lynn is responsible for overall service planning of primary health care and chronic disease within Nova Scotia Health Authority.

Tara SampalliTara Sampalli (NSHA), is the Assistant Director for Quality and Research in Primary Healthcare, Capital Health and Assistant Professor of Medical Informatics at Dalhousie University. Holding a Ph.D. degree in Health Informatics, Dr. Sampalli effectively blends research with practice bringing the novel concept of “embedded research” into healthcare. Her research interests include chronic disease management and multimorbidities, integrated models of care, knowledge management and application of innovative IT solutions in healthcare. 


Meghan RossiterMeghan Rossiter, BPhil, MA, is Regional Liaison, Collaboration for Innovation and Improvement, Canadian Foundation for Healthcare Improvement, located in the Atlantic Provinces. She brings a background in qualitative research linked to effective governance and public policy theories, with professional interest in health systems. She is responsible for supporting CFHI’s Atlantic Healthcare Collaboration (AHC) and INSPIRED Approaches to COPD Collaborative as a main point of contact. Meghan holds a Bachelor’s degree in Interdisciplinary Leadership from the University of New Brunswick’s Renaissance College program and a Master of Arts in Public Administration from the University of Ottawa.