Resources for Improving Chronic Care

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Long-term conditions have been described as “the healthcare challenge of the 21st century” by the World Health Organisation. This is due to the increasing burden of disease and mortality attributable to long-term conditions not only in developed countries, but increasingly in developing countries as well.

Consequently, extensive research and effort is going into improving the care of people with long-term conditions and here are some resources and international centres focusing on this area.

This page contains the following topics and links to sections below:

Examples of Useful Resources & Self Management Tookits
Assessment Tools
International Centres

Examples of Useful Resources & Self Management Toolkits

	Improving Your Practice Manual – this is an excellent resource designed for general practices and health organisations wanting to implement organisational change and improve chronic care. Based on years of work with practices applying the IHI Breakthrough Series methodology and small, incremental steps towards improvement. More information is available from the Improving Chronic Illness Care website Direct link to manual
	Health Disparities Collaboratives Training Manual for Improving Chronic Conditions - excellent overview manual as well as disease specific manuals for asthma, diabetes and depression. Need to log in (free to register) to Institute of Healthcare Improvement website to download zip file with all 4 manuals.
	Navigating Self Management - links directly to document. This is an excellent guide to the area of self management and chronic with a large range of resources, tools and information to support organisations with planning, implementation and evaluation of clinical programmes. Produced by the Whitehorse Division of General Practice in Australia. HIGHLY RECOMMENDED [Link to webpage] [full document - pdf, 168 pages, 5.8 MB]
	Supporting Chronic Disease Self-Management – experience from South Australia’s Eyre Peninsula This resource and related guides were funded by the Australian Government Dept of Health & Ageing. The guide and website contain information on self management & self management support, strategies, tools, case studies, learnings and models of care. Link to website Link to manual
	Partnering in Self Management Support: A Toolkit for Clinicians “The New Health Partnerships initiative is a national program of the Robert Wood Johnson Foundation at the Institute for Healthcare Improvement funded to develop and test efficient approaches to empower patients and families to manage their chronic conditions. The program also engages patients and families as advisors to improve the design and delivery of health care services.” May 2009 Toolkit – available via website below Website - large range of resources and information
	Physician Resource Guide to Patient Self-Management Support Produced by the American Medical Association, this guide is designed to introduce health providers to patient self management support concepts and presents selected resources and practice implementation tools. Webpage with range of resources Direct link to manual
	Ottawa Patient Decision Aids – part of the Ottawa Health Research Institute, affiliated with The Ottawa Hospital and The University of Ottawa. The Patient Decision Aids research program was developed to help patients and their health practitioners make “tough” healthcare decisions. “Tough” healthcare decisions may have many options, uncertain outcomes or benefits and harms that people value differently. Generic Ottawa Personal Decision Guide Interactive Patient Decision Guide version is available online Cochrane Systematic Review of Decision Aids – updated 2009 & Bibliography for Decision Aids International Patient Decision Aid Standards(IPDAS) Collaboration – website Ottawa Decision Support Tutorial - The ODST in intended for practitioners or others involved in counseling and supporting clients making decisions about health or social situations
	Improving care for people with chronic disease – a practical toolkit for clinicians and managers This is a practical toolkit for clinicians and managers to facilitate implementation of improvements for people with chronic disease. The toolkit is based on outcomes from NSW Chronic Care Collaborative and published by the NSW Department of Health. Published: August 2005
	Integrating Chronic Care and Business Strategies in the Safety Net Prepared by Group Health’s MacColl Institute for Healthcare Innovation, in partnership with RAND and the California Health Care Safety Net Institute. Agency for Healthcare Research and Quality. September 2008. Background information and manual

Assessment Tools

ACIC	organisations or practice teams	Assessment of Chronic Illness Care -useful survey tool developed by the Improving Chronic Illness Care (ICIC) team, used internationally by hundreds of organisations to assess where your practice or organisation is with implementing the chronic care model. [Overview] [Survey Versions] [Supporting Literature]
PACIC	patients	Patient Assessment of Chronic Illness Care- This survey tool was also developed by the ICIC team and gives a patient perspectiveof the quality of care provided by an organisation or practice team. “The survey includes 20 items, and should be sufficiently brief to use in many settings. When paired with the ACIC, these tools can provide complementary consumer and provider assessments of important aspects of care for chronic illness patients.” [Overview] [Survey tool]
CHAT	screening tool for use with patients	Case-finding and Help Assessment Tool for life-style and mental health assessment of adults(16 years and over) in primary health care. This is a useful 9 item validated tool developed by a multi-disciplinary team from Auckland University and led by Assoc Prof Felicity Goodyear-Smith. The tool assesses for physical inactivity, tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety and stress, abuse and anger problems. For each item (one or two questions) patients are asked whether this is something with which they would like help, either during this consultation or at a later date. CHAT Tool Sep 2008 More information & references
PCRS	use by healthcare teams	Assessment of Primary Care Resources & Supports for Chronic Disease Self Management -developed by the Robert Johnson Foundation Diabetes Initiative, March 2006 as an instrument that is congruent with the Chronic Care Model while expanding the self management component. PCRS Tool – pdf PCRS website and online version of the tool Paper – A quality improvement tool to assess self management support in primary care – 2007, Brownson CA, Glasgow RE et al: The Joint Commission Journal on Quality and Patient Safety, 33(7), pp.408-416 [view pdf]

International Centres

The MacColl Institute for Healthcare Innovation – Improving Chronic Illness Care is a national programme of The Robert Wood Johnson Foundation, with special interest in guidelines, specialty expertise and information systems for chronic care.
Institute for Healthcare Improvement – ‘The Institute for Healthcare Improvement (IHI) is a not-for-profit organisation driving the improvement of health by advancing the quality and value of health care.’
The Patient Education Research Centre at Stanford University, USA, led by Dr Kate Lorig. Stanford Patient Education Research Center is part of the Department of Medicine at the Stanford UniversitySchool of Medicine, U.S.A. Over the past 24 years, they have developed, tested, and evaluated self-management programmes for English and Spanish speakers with chronic health problems.
The World Health Organization: Observatory on Health Care for Chronic Conditions – large range of resources, reports, studies and information relevant to improving chronic care.
The Flinders Human Behaviour & Health Research Unit – Flinders University, Adelaide, Australia. A centre for research, evaluation and development of chronic condition management. This includes coordinated care, care planning, behavioural change and self-management and specialises in the education and training of health professionals and consumers.
Expert Patient Programme – National website for the British National Health Service Expert Patient Programme.
Ottawa Health Research Institute – The Ottawa Health Research Institute (OHRI) is the research arm of the Ottawa Hospital and a major part of the University of Ottawa Faculties of Medicine and Health Sciences. Website contains large range of health information and are the group that developed a range of evidence based decision aids.

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Page created by Dr Janine Bycroft: July 2009, updated March 2010.

DISCLAIMER: Health Navigator NZ is intended to provide general advice only. If you have any medical concerns, you should see your doctor. Health Navigator NZ information has been selected from a variety of consumer health resources and countries, therefore it is likely there will be some variations. All medical information needs to be carefully reviewed with your health care provider.