Developing a model for the shared care of chronic disease

Dr. June S. Bergman, University of Calgary
Dr. Alun Edwards, University of Calgary and Calgary Health Region
Dr. Peter Sargious, University of Calgary and Calgary Health Region
Dr. Sandra Delon, Calgary Health Region
Ms. Carol Slauenwhite, Calgary Health Region

Researchers from the University of Calgary partnered with the Calgary Health Region and health care providers in a three-year demonstration project to trial three different models of multidisciplinary team care for chronic diseases. Focusing on common chronic diseases, each model was evaluated by appropriate lab indices, self-care behaviours, and patient and provider satisfaction surveys. While all models demonstrated positive results, ongoing input from providers and patients resulted in the development of a hybrid model for implementation in all family physician offices across Calgary Health Region.


Considerable evidence in the research literature demonstrates that multidisciplinary health care provider teams result in better treatment of chronic disease. Since 1998, Calgary Health Region, in partnership with its physicians and the Government of Alberta, has supported the development of primary care teams for managing chronic disease through various funding initiatives, including the Health Transition Fund (HTF).

An early HTF funded-project involving Dr. June Bergman and Dr. Alun Edwards focused on multidisciplinary team building, partnering with the Calgary Health Region through their public health and home care portfolios. This two-year project involved six family physicians in their practices being partnered with home care nurses and public health nurses for the ongoing care of selected chronic diseases, and allowed barriers of union regulation and the development of shared practices to be worked through.

In 2000, the Calgary Health Region initiated a physician partnership program to support innovative ideas. This program funded over 30 business cases, one of which was based in part on the successful HTF project, and in part on a literature review and site visits of several multidisciplinary teams. This case, involving researchers from the University of Calgary, was funded as a demonstration project by Alberta's Health Innovation Fund and Alberta Province-Wide Services. Formal partnerships with the region's home care services, diabetes clinic, hypertension clinic, specialist and generalist physicians, and others were struck, with an intention to create a sustainable infrastructure if the project evolved favourably.

The KT initiative

Our goals for this demonstration project were: to demonstrate the value of multidisciplinary teamwork in the care of people with chronic disease; the impact of the team on quality of work life for the team members; and the impact of the model on the individual patient's chronic disease. In partnership with the health care professionals likely to be involved in the program, we operationalized the business plan developed earlier, choosing three different models of multidisciplinary team care that seemed to fit the local environment. Each model was funded for a period of three years.

Model One (case management) was built on a partnership between a physician and a home care nurse who initially partnered on the basis of overlapping practice, and then on a shared workload of chronic disease patients. In Model Two (focused case management), identified patients were assigned to a nurse/dietitian team over the period of the project. In Model Three (accessible expert), identified patients would be seen by an expert team from the diabetes education centre (usually a nurse and dietitian) on a one-off basis. Model Three also had specialist physician expertise available.

Each model was allocated to a group of approximately 20 primary care providers. Three common chronic diseases—diabetes, dyslipidemia, and hypertension—were chosen for use in the models because they were well studied in the literature, and allowed us to use intermediate indicators (such as hemoglobin A1C level in diabetic patients) as a proxy for outcomes.

Teams were directed to use clinical practice guidelines for the chosen chronic diseases. These guidelines were locally adapted by the generalist and specialist physicians initially, and later by the broader team. From the guidelines, a clinical care pathway was developed by the full team, the various roles of the team members were defined, and algorithms of care were developed for all the disease entities.

The models were evaluated by measuring appropriate lab indices, self-care, wellness scales, and patient satisfaction surveys, at baseline, one year, and two year time points. The team members were also interviewed in a structured manner for their perspectives on working in the team, particularly to identify strengths and weaknesses.

Results of the KT experience

The proposed model is now the region’s chosen model for chronic disease management, and is being implemented in all family physician offices across the Calgary Health Region.

All models demonstrated positive results in most laboratory indices. Self-care behaviours such as exercising, managing diet, and glucose testing, showed improvement in all models at the one-year mark, but not all behaviours were sustained throughout the two years. Wellness survey outcomes for the patients did not demonstrate any statistically significant improvement. There was a demonstrated loss of wellness perception that was assumed to arise from either education resulting in a better appreciation of the disease, and/or the natural downward course of the disease.

As a result of the evaluation, and from ongoing input from providers and patients, we were able to demonstrate which of the models would best fit in the Calgary Health Region. The proposed model, which is based on Model One (case management), with support from Model Three (accessible expert), is now the region's chosen model for chronic disease management, and is being implemented in all family physician offices across the Calgary Health Region.

Lessons learned

Partnerships at all working levels were an essential part of this project: within the care teams, within the research group, and between the various policy making bodies that impacted on our initial ability to do the project, and when it was successful, to roll out the results as a sustainable model for managing chronic disease in the Calgary Health Region.

Because so many of the ideas were new, much time was spent ensuring everyone understood the project goals. Initially, the two funding agencies, with their differing goals and objectives, were brought together to approve the project. Some reporting deadlines and deliverables had to be adapted. There was a request for evaluation of the team, another for the project to have a rural component, and another for a strong outcome consideration. However, the evaluation of all models was richer as a result of the partnership.

Engagement of both the project leaders and participants in many levels of policy making were crucial to the success of the project.

Flexibility was also important. Nothing could be left unquestioned, whether it was roles, clinical decisions, or policies. Over the three years of the project, participants were actively engaged in molding the models. This produced a very functional model, but was sometimes seen as a lack of strong leadership because of the rapid change in focus for the models.

Engagement of both the project leaders and participants in many levels of policy making were also crucial to the success of the project. Some held positions within the Calgary Health Region that allowed them to influence policy and budgetary decisions within their portfolios. Others worked within the health professional groups to develop policies and direction to support continued operation of multidisciplinary teams. In Alberta, this activity has resulted in many ongoing alternative fee plans, a new fee for physicians participating in some teamwork (to speak to home care nurses about patient care), the development of new local primary care networks of physicians and the development of the Health Professions Act.

At the health care provider level, a number of important factors for success for working in team-based models were identified. These included:

  • Initial co-location of members
  • Active engagement of all team members
  • Open communication
  • Shifting leadership roles, depending on expertise
  • Trust and respect between team members
  • Shared goals and readiness for change
  • Confidence in team competence
  • Evolution of roles and functions
  • Promotion of the team

Discussions with the team members also determined that success in teamwork was enhanced if members possessed professional assertiveness, strong clinical skills, communication skills, knowledge of the community and home care systems, the ability to contribute in case conferences, IT skills, and experience working in teams.

Physicians reported that their interest in participating in multidisciplinary teams was enhanced by prior involvement in similar projects, positive patient outcomes, reduced workload, and the opportunity to participate in system change. They noted a number of barriers to working within such models, however, including reimbursement, space, and difficulty in maintaining strong leadership and direction.

Conclusions and implications

Our project was based on a rapid-cycle model of change, which raised many new questions and sparked additional projects. Chronic disease management within the Calgary Health Region has now expanded from the original three areas of diabetes, hypertension and dyslipidemia to include chronic obstructive pulmonary disease and congestive heart failure. Each of these conditions will be included in our blended chronic disease management model now being implemented across the region. Calgary Health Region also has a new chronic disease information management system, and is making early steps to support the province's electronic health record.

A team has also been working with patients to identify the need for community resources in education, diet, and exercise for those with chronic diseases. This has resulted in a program in Calgary that provides safe places for people with chronic disease to exercise, and is itself a partnership between the Calgary Health Region and designated fitness and community facilities. People can be referred from the chronic disease program or can self-refer, but in the spirit of the new partnership model, all people going through the program are required to obtain their family physician's approval prior to participating in the exercise program.

The case management model (Model One) is now being piloted in Ontario to determine if the principles of multidisciplinary teamwork as outlined in Calgary are transferable across jurisdictions. This national partnership project also has a significant information technology component, and is attempting to bring IT to the team in a manner that enhances the work they do.

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