Integrated complex chronic disease management.
Building on the work of the last three years, integrated complex chronic disease management remains a priority. This priority reflects two key developments: substantive and growing health system needs, recognizing that people experiencing chronic diseases do not have a single health issue but rather multiple needs as a result of their condition; and secondly, that St. Joseph’s now holds a major leadership role in this growing area of health care for the future.
Much has been accomplished. Physicians, teams and partners were engaged in the development of a comprehensive blueprint to guide the path and priorities for how we will wrap specialty care and teams around the multiple, complex and like needs of patients in an effort to achieve improved outcomes and a better overall patient experience.
Implementation of the blueprint and indeed, integration of care and services in a number of areas has been successfully launched at our St. Joseph’s Hospital site, but it will not be exclusive to this location. While team integration efforts, particularly with health system partners, continues in many ways across the organization, the intent is to gradually engage and extend the work of the blueprint across sites, following the needs of patient groups. One example of this broader integration is in dementia care. The blueprint’s next steps are in Diabetes and Cardiac Rehabilitation; Asthma, Chronic Obstructive Pulmonary Disease (COPD) and Allergy; and then Rheumatology and Pain Management.
By 2018, we will be recognized as leaders in integrated chronic disease management for those living with complex chronic disease. Patients will experience a convergence of specialty care around them. Instead of multiple visits and interactions through our system, patients will be at the centre of care processes. As an academic health care system, we will have a learning environment in which our own teams and the students of the multiple disciplines we teach are continuously benchmarking and implementing best practice approaches. We will have strengthened the integration of research and knowledge translation within care delivery through the addition of the clinical trials unit at St. Joseph’s Hospital.
Chronic diseases are not, by definition, curable and they require ongoing management by care providers and adaptation by patients. Most individuals with chronic disease have more than one of these diseases (e.g. the triad of diabetes, cardiovascular disease and depression.)
It is increasingly recognized that care for individuals with chronic diseases tends to be fragmented into specialty “silos” each managing their “piece” of the patient with little coordination across the spectrum of chronic diseases. Although primary care providers do their best to coordinate care for their patients, the lack of overall coordination often results in care fragmentation and frustration for them and their patients.
Toward Integrated Chronic Disease Management Services, St. Joseph’s Health Care London