Resources for improving chronic care

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.

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.

Examples of useful resources & self management toolkits

	Self-Management Support Toolkit (NZ) Developed by the Health Navigator team, this toolkit provides a range of useful tools, resources, programme information and tips for increasing the support we provide patients/clients or service users to manage more effectively at home. Visit the Toolkit section
	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.
	NZ Telehealth Resource Centre Provides resources and advice to clinicians and practices who are considering or planning to implement a telehealth service. To help encourage the uptake of telehealth by health professionals across the country. “Telehealth is changing the way we deliver healthcare and is a good example of how the sector is harnessing IT to provide better services to patients closer to home,” says Dr Coleman. (Source: Beehive.govt.nz – New online telehealth resource to encourage uptake).
	CEO Checklist Participants in an Institute of Medicine Roundtable on Value & Science-Driven Health Care have developed a checklist of critical components for organisations interested in delivering high value health care. The following ten items are discussed with brief examples in the document. Foundational elements Governance priority—visible and determined leadership by CEO and Board Culture of continuous improvement—commitment to ongoing, real-time learning Infrastructure fundamentals IT best practices—automated, reliable information to and from the point of care Evidence protocols—effective, efficient, and consistent care Resource utilization—optimized use of personnel, physical space, and other resources Care delivery priorities Integrated care—right care, right setting, right providers, right teamwork Shared decision making—patient–clinician collaboration on care plans Targeted services—tailored community and clinic interventions for resource-intensive patients Reliability and feedback Embedded safeguards—supports and prompts to reduce injury and infection Internal transparency—visible progress in performance, outcomes, and costs
	Navigating Self Management This is an excellent guide to the area of self management and chronic care 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. full document pdf, 168 pages, 5.8 MB
	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 Website - large range of resources and information. Need to log in (free) for this resource
	Ottawa Patient Decision Aids Developed by 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
	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 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 Improving Chronic Illness team and gives a patient perspective of 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. Useful 9 item validated tool developed by a multi-disciplinary team from Auckland University and led by Professor 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 The eCHAT Program to Facilitate Healthy Changes in New Zealand Primary Care. Felicity Goodyear-Smith, James Warren, and C. Raina Elley J Am Board Fam Med 2013;26 177-182 Link to abstract and full article
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 UK version 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.
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.

Page last updated: 15 Jan 2020