Increasing the involvement of specialist physicians in chronic disease management

Abstract

Background: The Capital Health (CH) region in Alberta serves the population of the Edmonton area as well as a large referral population in western Canada. CH is responsible for the delivery of the spectrum of patient care, from inpatient to outpatient services. Growth in outpatient care, in particular, has led to the development of several ambulatory care facilities from which the delivery of care to several populations with a chronic disease will be coordinated.

Assessment of problem: The traditional model of care delivery is unsuited to the management of chronic diseases. Physicians must be part of the planning and implementation of new models if they are to be successful and sustainable. The concept of integration into a delivery team is not well understood or practised. This is not conducive to the integration of specialist physicians into multidisciplinary teams in ambulatory care that serves the needs of patients from a large geographic area.

Results: Chronic disease management using the Chronic Care Model has proven to be an effective method of delivering care to this wide population. Specialist physicians have not always taken advantage of opportunities to be involved in the planning and development of such new health care projects. In CH, physician integration in the planning, development and implementation of this new model has proven vital to its success.

Strategies for change: We based our strategy for change on Wagner's Chronic Care Model. This involved eight steps, the first four of which have been completed and the fifth and sixth are underway.

Lessons and messages: Five factors contributed to the successful integration of specialist physicians in chronic disease management: collaboration between disciplines and organizations; creating patient-centred services; organizational commitments; strong clinical leadership; and early involvement of clinicians.