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Implementation and evolution of a regional chronic disease self-management program.

Clare Liddy1,2, Sharon Johnston3,4, Kate Nash3

  • 1C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada, 43 Bruyère Street, Annex E, Room 106, K1N 5C8. cliddy@bruyere.org.

Canadian Journal of Public Health = Revue Canadienne De Sante Publique
|August 16, 2016
PubMed
Summary

A community-based self-management program effectively supports individuals with chronic diseases. This initiative trained peer leaders and healthcare providers, leading to widespread adoption and sustainable funding across Ontario.

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Area of Science:

  • Health Services Research
  • Chronic Disease Management
  • Behavioral Science

Background:

  • Chronic diseases require ongoing self-management support.
  • Office-based strategies alone are insufficient for sustained behavior change.
  • Community-based programs can complement clinical interventions.

Purpose of the Study:

  • To establish a comprehensive, community-based program for chronic disease self-management.
  • To improve and sustain self-management support for patients.
  • To complement existing office-based behavior change strategies.

Main Methods:

  • Created Living Healthy Champlain (LHC), a regional organization.
  • Provided peer leader training for the Stanford Chronic Disease Self-Management Program (CDSMP).
  • Offered skills training in behavior change approaches for healthcare providers.
  • Supported organizations in integrating self-management support.
  • Evaluated program impact using the RE-AIM framework.

Main Results:

  • Delivered 232 CDSMP sessions at 127 locations, reaching ~4,000 patients.
  • Trained over 300 peer volunteers, with 98 remaining active.
  • Trained 1,327 additional providers in self-management support models.
  • Grew from a pilot to a provincially funded regional initiative.
  • Adopted as a provincial model for service delivery.

Conclusions:

  • Community-based self-management programs, in partnership with primary care, are effective.
  • Broad implementation is feasible for supporting patients with chronic conditions.
  • Sustainable models can be developed for enhanced self-management support.