Chronic Disease Management and Prevention

Chronic diseases are among the most common and costly health problems facing Canadians; they are also among the most preventable.

Working with our partners, we seek to identify opportunities to support provincial priorities, encourage healthy living and support best practice management of complex conditions along the continuum of care - from prevention and early detection to the end of life.  

Chronic disease management and prevention is one of the priorities of Central LHIN's Integrated Health Service Plan 2010-2013. The goals of this priority include:

• Support the Ontario Diabetes strategy
• Collaborate with the Ontario Renal Network
• Enhance self-management supports for chronic disease
• Improve primary and secondary prevention of chronic disease

Primary areas of focus include:

1.      Ontario Diabetes Strategy

• Diabetes Regional Coordinating Centre – Central LHIN        
• Self-Management Program
• Enhanced Diabetes Education Programs
• Diabetes Passport and Goal Card
• Prevention in Diabetes Program
• Diabetes Testing Reports

2.      Ontario Renal Network

3.      Ontario Stroke Network

• Stroke Prevention Clinics

Ontario Diabetes Strategy

In 2008, the government announced an investment of $741 million over four years (2008/09 to 2011/12) in the Ontario Diabetes Strategy (ODS) to expand diabetes programs and improve the health and health care for Ontarians living with diabetes or at risk of developing diabetes. Through the ODS, the government has built on existing investments in prevention and care initiatives at each level of the health system to build capacity, make it easier for people to get the services they need and improve the overall quality of diabetes services and care in Ontario. The two key objectives of the Strategy are: 

• Leveraging existing and making new investments in diabetes care to improve access to, and quality of, diabetes services and care in Ontario; and 
• Building capacity in the system by enhancing prevention and improving diabetes management. 

In March 2011, Central LHIN and the Ontario Medical Association (OMA) held a physician engagement session, Building Capacity for Diabetes Management in Primary Care,  to increase awareness of both the Central LHIN approach to primary care and the Ontario Diabetes Strategy. A key theme was the importance of engaging family physicians in the discharge planning of patients as they transition out of the hospital and into the community.

Diabetes Regional Coordinating Centre – Central LHIN
In 2010, as part of the Ontario Diabetes Strategy, fourteen Diabetes Regional Coordinating Centres were launched by the Ministry of Health and Long-Term Care, one in each of the Local Health Integration Networks across Ontario.  In Central LHIN, Southlake Regional Health Centre is the host for the Diabetes Regional Coordinating Centre (DRCC). The DRCC has the mandate to work with the LHIN and service providers to coordinate and align diabetes care, and promote the best possible health outcomes for people with the disease.  The DRCC in Central LHIN has a strong team of clinical, administrative and data experts who are working on several initiatives to improve diabetes care in our region.

For more information about diabetes services in our region, contact Maureen Wilkinson, Administrator, Diabetes Regional Coordinating Centre – Central LHIN at mwilkinson@southlakeregional.org or 905-895-4521 ext. 6417.

Self- Management Programs
A key component of the Ontario Diabetes Strategy is improving self-management support for Ontarians with or at risk of diabetes. In February 2011, the Ministry announced that Southlake Regional Health Centre would host a Self-Management Initiative in Central LHIN. The objective of the Self-Management Initiative is to provide individuals with the knowledge, skills and confidence to effectively self-manage their diabetes, thereby improving their health outcomes and reducing long-term health care costs. This will be facilitated by providing targeted education and skills training for both individuals with or at risk of diabetes, and their health care providers.

For more information on how to participate in the Self-Management Project – if you are an individual with or at risk of diabetes, or a health care provider, contact Anne Till at atill@southlakeregional.ca or 905-895-4521 ext. 6656.

Enhanced Diabetes Education Programs
In 2010-2011, the Ministry of Health and Long-Term Care announced a service expansion for diabetes education teams to improve access to diabetes education in communities of highest need. The following diabetes education programs were awarded expanded services:

Diabetes Passport and Goal Card
To further support individuals' management of diabetes, the ODS has introduced a Diabetes Passport and Goal Card. In partnership with health care providers, Ontarians with diabetes can use the Diabetes Passport and Goal Card to record, track and monitor important information such as key test results, medications, diabetes education sessions, personal goals and planned activities to assist in self-management of their diabetes.

Prevention in Diabetes Program
To support the prevention of diabetes, the ODS has awarded Markham Family Health Team funding for a three year pilot program focused on intensive lifestyle intervention, specifically supporting weight reduction and increasing physical activity for people who are at risk for developing diabetes, and its related complications. This program is available to Central LHIN residents.

Diabetes Testing Reports
There are three key tests that people living with diabetes should receive on a regular basis. They are:

• the HbA1C blood glucose test, which is recommended at least every six months;
• the LDL-C cholesterol test, which patients should receive at least every year; and
• a retinal eye exam, which patients should receive at least every two years.

The Diabetes Testing Reports are part of the Baseline Diabetes Dataset Initiative (BDDI) and supports the Ontario Diabetes Strategy by informing primary care providers about the timing of test dates for the HbA1C test, LDL-C test and retinal eye exams of their patients with diabetes, which can assist patients and their provider to better manage their diabetes care.

The Ministry of Health and Long-Term Care’s Ontario Diabetes Strategy’s Baseline Diabetes Dataset Initiative (BDDI) will be sending an updated Diabetes Testing Report (DTR) to participating primary health providers across the province in Summer/Fall 2012. Since its inception in May 2010, over 6,300 primary care providers have joined the initiative and received DTR listing testing dates for three key diabetes tests (blood glucose, cholesterol, retinal eye exam) for over 619,500 adult Ontarians with diabetes.

Improved management of diabetes can have significant benefits for individuals with diabetes and their families. The ministry is committed in its drive to help Ontarians living with diabetes, and the BDDI is an important part of this commitment. In Fall 2011, a public notice campaign ran online and in print media to notify Ontarians of the fourth wave of the BDDI.  Similar to the three previous notices, this notice informed Ontarians about the collection, use and disclosure of personal health information as part of this important initiative. Copies of this notice and details regarding withdrawing or reinstating consent can be found at the Ministry's website. More details about the Diabetes Testing Report and other information about the Ontario Diabetes Strategy can be found at www.ontario.ca/diabetesor by calling 1-800-291-1405 (TTY: 1-800-387-5559).  

• Public notice - Diabetes Testing Report - August 2012
   

Ontario Renal Network

The Ontario Renal Network (ORN) provides overall leadership and strategic direction to organize and manage the delivery of renal services in Ontario. In 2010, regional renal programs were established in all 14 LHINs. The goals of the ORN are as follows:

• Prevent or delay the need for dialysis
• Broaden appropriate chronic kidney disease patient care options
• Improve the quality of all stages of chronic kidney disease care
  
  Renal services and dialysis planning is advised by a Regional Renal Steering Committee (RRSC) for Central LHIN, led by the Regional Director, Melanie Tremblay (mtremblay@hrrh.ca) and Clinical Director, Dr. Andre Charest.

Ontario Stroke Network

In 2008, the Ministry of Health and Long-term Care established the Ontario Stroke Network (OSN), a network of regional and district stroke centres with the ultimate vision of Fewer Strokes. Better Outcomes. OSN is focused on system change, professional education and public awareness through the following: implementing best practices across the care continuum, conducting research and evaluation, and planning, implementation and service.

Stroke Prevention Clinics
In 2009, a collaborative approach amongst five hospitals in Central LHIN, led by Mackenzie Health (formerly York Central Hospital) as the designated District Stroke Centre, has resulted in the successful implementation of a network of stroke prevention clinics.  Once timely, standardized and evidenced-based preventative care for patients with transient ischemic attack or minor stoke is achieved at the nurse-practitioner run clinics, patients are encouraged to attend local Cardiovascular Rehabilitation programming to address ongoing lifestyle behaviours and risk factors for stroke (for example, diabetes, high blood pressure, lack of exercise). The goal of this initiative is to improve access to best practice stroke prevention services in order to reduce the incidence of primary or secondary stroke.

For more information on the Stroke Prevention Clinics, contact, Judy Murray at judy.murray@mackenziehealth.ca or (905) 883-1212 x3882. 

Additional provincial CDMP priorities in Central LHIN include:

Central Regional Cancer Program
The Regional Cancer Program of the Central LHIN, hosted by Southlake Regional Health Centre oversees the delivery and quality of cancer services for residents of North York, York Region and South Simcoe. It is one of 13 Regional Cancer Programs under the leadership of Cancer Care Ontario to ensure cancer care services are delivered according to province-wide quality standards.

Regional Cardiac Care Program
The York, Simcoe, Muskoka, Dufferin Cardiac System Planning Team works collaboratively to continuously evaluate and advance access, quality and efficiency of cardiac care. The Regional Cardiac Care Program is hosted at Southlake Regional Health Centre.