Developing a chronic disease management service framework

Chronic disease management (CDM), a phrase common to people living with chronic disease, jumped from the pages of reports on primary health as far back as 1978 and onto the lexicon of elected officials around the time of the 2003 First Ministers’ Accord on Health Care Renewal. CDM is rooted in primary health care, and primary care is the foundation of Canada’s health care system. One of the focus areas for developing strategies for advancing health care renewal at the primary level is by early detection and action; the heart of which is health promotion, disease prevention and chronic disease management. In British Columbia the development of a service framework for chronic disease management centers on high-risk populations and specific chronic diseases. Arthritis and Osteoporosis is currently under development.

The strategic process of developing a comprehensive model for CDM is intricate and involves provincial health ministry staff, arthritis and osteoporosis representatives, health care professionals, and consumers. Other provinces have, or are developing their own models. I am one of the consumers involved in the B.C. working group and just recently was asked by a friend, newly diagnosed with osteoarthritis, to explain what I was doing. To assist me in describing how a service framework is developed, I have turned to the experts in the field, Dr. Chris Rauscher, Health Ministry lead on service frameworks and Dr. Treena A. Chomik, a consultant with a service framework background.

What are service frameworks?

Service frameworks guide health system improvement and system redesign. In BC they are defined as “a patient-centred approach to improving health outcomes across the conventional boundaries of the heath system.” They are companion documents to clinical practice documents and go beyond the patient-physician relationship to address services from all providers across the health continuum, including health and community agencies that touch on the broader determinants of health. Recognizing their reach, some people have referred to service frameworks as “system guidelines.”

Service frameworks represent a high-level picture of optimal care for people with a particular illness or health condition. They do not attempt to prescribe care; rather, they suggest what services individuals should expect to receive, based on optimal pathways of care.

While service frameworks may suggest some tools and strategies to support implementation, they do not drill down to precisely identify who should do what, when, or how. Instead they offer a menu of priority recommendations that allow all partners in the health system – patients, providers, researchers, health and community agencies, health authorities and ministries – to define how they will contribute to improved services and better health outcomes for patients living with disease. In this way, service frameworks are meant to be adaptable to different regions, conditions and populations.

Why is B.C. using the service framework approach?

The service framework approach to CDM is recognized in the United Kingdom, Australia and BC as a means to improve care for people living with chronic disease and conditions. Moreover there has been an established process for developing physician guidelines and widespread expressed interest in looking at systems improvement in a broader framework. In addition, there was interest in looking at the systems from the “person” perspective.

What does a service framework look like?

The service framework matrix pictured below guides the development of standards for the management of rheumatoid and osteoarthritis and osteoporosis. For the past several months a core group of representatives from the provincial Ministry of Health, The Arthritis Society, The Osteoporosis Society and consumer groups have been meeting to “populate” the matrix with standards of care and best practice recommendations across the four levels of health status and four levels of health care.

Table 2: Table Arthritis/Osteoporosis Service Framework Matrix – A Way Forward

How does the process work?

The key elements involved in populating the matrix are gathering, reviewing and plotting gold standard sources of evidence. This includes practice guidelines, service framework documents from other jurisdictions (UK, Australia), planning and policy documents, published peer-reviewed articles (especially review articles), and organizational or coalition documents (e.g. from patient/advocacy groups).

What is the anticipated completion date?

The initial draft of the service framework will be finished this fall. But the process doesn’t end there. Once the populated is finished, the framework will be reviewed and edited for language, grouping and sequencing of recommendations, redundancy and gaps. It will then be passed to the Provincial Working Group, other physicians and allied health professionals where levels of evidence will be assigned, recommendations prioritized, and performance indicators/measures identified. Four or five patient focus groups will be convened to collect their views on care and to “ground in” patient experience. Again the framework will be reviewed by the Core Working Group and then passed to the Provincial Working Group for final approval. A sign-off committee and process is currently being established for services frameworks in BC.

Will CAPA members have the opportunity to review the finalized service framework?

Yes. I have been assured that the completed document will be available for distribution in the spring of 2007. In the meantime, let me know what the Ministry of Health is doing in your province to fulfill the First Ministers commitment to primary health care reform. Are chronic disease management strategies being developed and is arthritis among the top three priority diseases?