A Patient-Centred Approach to Managing Chronic Disease in Atlantic Canada

Atlantic Health Collaboration team imageIn 2012 the Canadian Foundation for Healthcare Improvement teamed up with the 17 Atlantic Regional Health Authorities in Newfoundland and Labrador, Prince Edward Island, New Brunswick and Nova Scotia to lead a three-year patient-centred collaboration aimed at improving healthcare for people in the Atlantic provinces living with chronic disease.



The objectives were to:

  1. develop a patient- and family-centred approach to chronic disease management;
  2. promote the sustainability of the health system; and
  3. help build a network of organizational, regional and provincial teams which will share evidence-informed, effective, sustainable and systems-level solutions and work together to develop and implement improvement projects.

The Approach

The foundation of the collaboration is rooted in a charter [hyper link charter] setting the terms of the collaboration, signed by the regional health authority CEOs and endorsed by provincial departments of health. Atlantic CEOs and senior VPs governed the collaboration with CFHI leadership through an Executive Committee and costs were supported across regions through a cost-sharing agreement. Reliance on regional needs and local expertise to support teams, as well as emphasis on connecting delivery to the policy sphere has been instrumental to sustaining improvements. Each team was also supported by both an academic mentor – an expert in connecting evidence to practice in disease-specific areas – and improvement coach, experts in change management and QI processes.

Eleven improvement projects in four provinces

CFHI supported 11 improvement projects, led by multidisciplinary teams including front-line clinicians and managers focused on mental illness, diabetes, chronic obstructive pulmonary disease (COPD) and multimorbidity. In a region with greater risk factors for and higher rates of chronic disease than the average Canadian, teams were successful in driving quality improvement, gaining quality improvement skills and bridging new pan-regional connections to support future improvements. See descriptions of team initiatives for results from each of the 11 improvement teams.

Impact stories from five of the health region teams involved >>

AHC Supported Teams infographic

Participating Sites and Topics