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Can J Diabetes 37 (2013) 254e259

Canadian Journal of Diabetesjournal homepage:

www.canadianjournalofdiabetes.com

Perspectives in Practice

Alberta Healthy Living ProgrameA Model for Successful Integration of ChronicDisease Management Services

Louise Morrin BSC (PT), MBA *, Judith Britten MSc, Shahnaz Davachi RD, PhD, Holly Knight RD, MEd, PhDAlberta Health Services, Calgary, Alberta, Canada

a r t i c l e i n f o

Article history:Received 11 October 2012Received in revised form5 December 2012Accepted 2 April 2013

Keywords:chronic disease managementcommunity-baseddiverse and vulnerable populationsintegrationmultimorbidity

Mots clés :Prise en charge de la maladie chroniquecommunautairepopulations diversifiées et vulnérablesintégrationmultimorbidité

* Address for correspondence: Louise Morrin, BSServices, 10101 Southport Rd SW, Calgary, Alberta T2

E-mail address: louise.morrin@albertahealthservic

1499-2671/$ e see front matter � 2013 Canadian Diahttp://dx.doi.org/10.1016/j.jcjd.2013.04.001

a b s t r a c t

The most common presentation of chronic disease is multimorbidity. Disease management strategies aresimilar across most chronic diseases. Given the prevalence of multimorbidity and the commonality inapproaches, fragmented single disease management must be replaced with integrated care of the wholeperson. The Alberta Healthy Living Program, a community-based chronic disease management program,supports adults with, or at risk for, chronic disease to improve their health andwell being. Participants gainconfidence and skills in how to manage their chronic disease(s) by learning to understand their healthcondition,makehealthyeating choices, exercise safelyandcopeemotionally. Theprogram includes3 servicepillars: disease-specific and general health patient education, disease-spanning supervised exercise andBetter Choices, BetterHealthTM self-managementworkshops. Services aredelivered in the communitybyaninterprofessional team and can be tailored to target specific diverse and vulnerable populations, such asAboriginal, ethno-cultural and francophone groups and those experiencing homelessness. Programsmaybeoffered as a partnership between Alberta Health Services, primary care and community organizations.Common standards reduce provincial variation in care, yet maintain sufficient flexibility to meet local anddiverseneeds and achieve equity in care. Themodel has been implemented successfully in 108 communitiesacross Alberta. This approach is associated with reduced acute care utilization and improved clinicalindicators, and achieves efficiencies through an integrated, disease-spanning patient-centred approach.

� 2013 Canadian Diabetes Association

r é s u m é

La manifestation la plus fréquente de la maladie chronique est la multimorbidité. Les stratégies de prise encharge de la maladie sont similaires dans la plupart des maladies chroniques. Étant donné la prévalence dela multimorbidité et la similitude des approches, la prise en charge fragmentée d’une seule maladie doitêtre remplacée par les soins intégrés de la personne entière. L’Alberta Healthy Living Program, un pro-gramme communautaire de prise en charge de la maladie chronique, soutient les adultes ayant unemaladie chronique ou étant exposés à un risque de maladie chronique dans l’amélioration de leur santé etde leur bien-être. Les participants gagnent en confiance et acquièrent des compétences sur la manière deprendre en charge leur ou leurs maladies chroniques en apprenant à comprendre leur état de santé, à fairedes choix alimentaires sains, à faire de l’exercice de façon sécuritaire et à faire face aux émotions. Leprogramme inclut 3 piliers de service : l’enseignement propre à la maladie et de la santé générale aupatient, l’exercice supervisé tout au long de la maladie et les ateliers de prise en charge autonome BetterChoices, Better HealthTM. Les services sont offerts dans la communauté par une équipe inter-professionnelle et peuvent être adaptés pour cibler les populations diversifiées et vulnérables telles queles Aborigènes, les groupes ethnoculturels et francophones, et les sans-abris. Les programmes peuventêtre offerts en partenariat entre les Alberta Health Services, les soins de santé primaires et les organisa-tions communautaires. Les standards communs réduisent la variation provinciale des soins, qui ont encoreune flexibilité suffisante pour répondre aux besoins locaux et divers, et atteindre l’équité en matière desoins. Le modèle a été mis en place avec succès dans 108 communautés de l’Alberta. Cette approche estassociée à la réduction de l’utilisation des soins de courte durée et à l’amélioration des indicateurs clin-iques, et réalise des gains d’efficience par l’approche intégrée axée sur le patient tout au long de lamaladie.

� 2013 Canadian Diabetes Association

C (PT), MBA, Alberta HealthW 3N2, Canada.es.ca.

betes Association

L. Morrin et al. / Can J Diabetes 37 (2013) 254e259 255

Introduction

The prevalence of chronic disease is increasing, with the mostcommon presentation being multimorbidity, the co-existence of2 or more chronic diseases (1,2). Furthermore, the burden ofchronic disease is not equitable across the population. Specificvulnerable populations have higher rates of chronic disease due togenetic factors and complex social determinants (3). Diseasemanagement strategies, such as eating healthy, being physicallyactive, avoiding tobacco and coping emotionally, are similar acrossmost chronic diseases. Given the prevalence of multimorbidity andthe commonality in approaches, fragmented single diseasemanagement must be replaced with integrated care of the wholeperson to achieve both health system efficiencies and a morepatient-centric approach. Additionally, improved access to chronicdisease management (CDM) services is required for high needsvulnerable populations who face multiple challenges accessingmainstream services because of complex and interrelated cultural,social, economic and systemic barriers (4).

The purpose of this paper is to describe the Alberta HealthServices (AHS) Alberta Healthy Living Program, an integrated,community-based CDMmodel. Rather than the traditional disease-specific orientation, the approach uses a noncategorical patientorientation to better meet the needs of people living with a rangeof chronic diseases, and is adaptable to address the needs of specificvulnerable populations.

Program Description

The AHS Alberta Healthy Living Program (AHLP) is an integratedcommunity-based CDM approach that supports adults with, or atrisk for, chronic disease to improve their health and well being.Alberta’s chronic disease strategy and services are based on thefollowing foundational principles: 1) Expanded Chronic CareModelis the framework for chronic disease prevention and managementin Alberta (5); 2) empowerment of patients to effectively managetheir chronic disease through general health and disease-specificeducation, supervised exercise and self-management support(6e11); 3) addressing broader determinants of health to enhanceaccess for diverse and vulnerable populations (12); 4) serviceprovision by a collaborative and competent interprofessional team(13); 5) integration and delivery of services in partnership with theheath system and community (14); 6) application across chronicconditions (15).

Figure 1. Conceptual dia

Program Components

The AHLP includes three service pillars: patient education,supervised exercise and self-management support.

Patient education programs are delivered by an interprofes-sional team and address both the disease-specific and generalhealth needs of participants. Disease-specific education programsfor participantswith diabetes, hypertension, dyslipidemia, ischemicheart disease, chronic obstructive pulmonary disease, obesity,arthritis and osteoporosis are facilitated by either AHLP staff or inpartnership with providers from specialty clinics. Additionalchronic diseases are addressed in larger and more establishedprograms, including Parkinson’s disease, cancer survivorship,fibromyalgia, chronic kidney disease, chronic pain and stroke.

Supervised exercise programs include both centre- and home-based approaches and are adapted to meet the needs of partici-pants with a variety of chronic conditions. Disease-specific needscan be addressed within an integrated, disease-spanning program,eliminating the requirement for replication of core services for eachdisease specific population. Programs are typically 8 to 12 weeks induration, although may be tailored to individual needs.

Self-management supports are embedded across the continuumof care and are offered through disease-spanning workshops, toolsand integrated messaging. Better Choices, Better HealthTM work-shops ([Stanford’s Chronic Disease Self-Management Program], ledby trained lay leaders or staff, are integrated into the AHLP, as wellas the MyHealth.Alberta.ca personal health portal. Innovativeself-management support frameworks, tools and curricula forproviders are being developed to further build self-managementsupport and patient-centred skills in Alberta’s health care pro-viders. For example, a Self-Management and Complex Care Plan-ning Workbook, available to primary care teams, aligns with aprovincial fee code for family physicians supporting annual careplanning with individuals who have chronic disease. A system-wide approach to integrate health behaviour change into all as-pects of care is currently being piloted to support self-management.Partnerships support the delivery and expansion into more com-munities of Better Choices, Better HealthTM in-person and on-lineworkshops to meet the needs of current and new prioritycommunity-based CDM programs.

AHLP is integrated into specific chronic disease clinical path-ways and referral pathways across the continuum. A conceptualcare pathway illustrates how the AHLP is integrated into the carepathway for an individual with diabetes (Figure 1). Participants

betes care pathway.

L. Morrin et al. / Can J Diabetes 37 (2013) 254e259256

may enrol in 1, 2 or all 3 service pillars. Programs are delivered byAHS, primary care or the community, and are located in the com-munity (such as gyms, community and cultural centres, rental hallsand churches) so all individuals can have timely and equitable ac-cess to the services they require. For optimal implementation ofAHLP programs, specific supports have been identified that alignwith the Chronic Care Model (Figure 2)dspecifically, program ad-aptations to accommodate diverse and vulnerable populations,partnerships and support of workforce competency developmentthrough provider education.

Given differences across Alberta related to population diversity,level and nature of disparities and access challenges and gaps, theAHLP components have been or are being modified to meet theunique needs of diverse and vulnerable populations. An innovativeprovincial framework and action plan entitled “Targeted ChronicDisease Prevention and Management Approach for Diverse andVulnerable Populations” is being implemented to ensure enhancedand equitable access and outcomes for Alberta’s diverse andvulnerable populations through addressing broader determinantsof health.

The initial priority populations for targeted programminginclude:

� Ethno-cultural populations (immigrants, high-risk visibleminorities, refugees);

Figure 2. Alignment of integrated community-based chronic disease management and the cthe American College of Physicians]: Wagner EH. Chronic disease management: “What will i

� Hutterites and low-German-speaking Mennonites living inremote rural settings;

� Aboriginal people;� Francophone population;� People experiencing homelessness.

Targeted programs are supported by a provincial diversity teambased on the following: developing innovative and modified ap-proaches; enhancing providers’ diversity awareness and skills; andsupporting AHS zones and diverse communities to build capacityand modify, develop and implement new programs where gapsexist.

Partnerships

Key partnerships have been formed between local CDM teams,primary care and communities. This is intended to avoid duplica-tion and optimize services through a coordinated approach toservice planning, considering population needs and primary care/community priorities and capacity. This may include:

� Collaborating to share the delivery of patient education andself-management programs;

� Developing care pathways to identify patient flow, referralpoints and provider roles;

hronic care model. Graphic adapted from the Chronic Care Model [with permission byt take to improve care for chronic illness?” Effective Clinical Practice 1998;1(1):2-4.17

Figure 3. Alberta Healthy Living Program: Sites and Services.

L. Morrin et al. / Can J Diabetes 37 (2013) 254e259 257

� AHS supporting primary care in enhanced CDM practicedevelopment, providing resource materials, practice guide-lines, provider education and mentorship;

� Multilingual and multicultural interprofessional teams in pri-mary care practices that serve a high concentration of ethno-cultural populations.

Care continuity and communication are maintained throughnotification to family physicians of their patient enrolment,provision of intake and follow-up assessment results and consul-tation with primary care for participant-specific issues.

Community engagement and partnerships leverage commu-nity resources and provide opportunities to address servicegaps. This includes an enhanced understanding of the

community’s perspective of needs and access barriers, identifi-cation of community resources that could support the AHLP anddefinition of the role of the community in service deliverypartnerships.

Examples of communityeAHLP partnerships include:

� Local recreation groups offering the supervised exercisepillar with AHS supporting staff training, and participantassessments;

� A seniors’ centre offering Better Choices, Better HealthTM

workshops with AHS-trained volunteer leaders;� Trained Aboriginal or Community Health Workers supportingdiabetes awareness and prevention initiatives targeted to anAboriginal or visible minority populations.

Figure 4. Healthcare utilization in participants: Baseline vs. 1 year. ED, Emergencydepartment; IP, in-patient

L. Morrin et al. / Can J Diabetes 37 (2013) 254e259258

Implementation

The creation of AHS and a provincial CDM unit provided theincentive to design a common provincial approach under the AHLPbanner, moving from pre-existing disease-specific or single-serviceCDM programs to integrated, disease-spanning programs. MostAHS zones are offering all three service pillars of the AHLP in anintegrated approach. A 2011 environmental scan revealed that 1 ormore of the 3 AHLP service pillars was offered in 108 communitiesin Alberta, serving a total of approximately 25 000 Albertans peryear (Figure 3).

To support province-wide adoption of the AHLP model, aknowledge translation strategy was developed that targeted pri-mary care providers, zone leaders, AHS Executive, Strategic ClinicalNetworks and CDM health care providers. This strategy includedsupports outlined previously (diversity adaptation, provider edu-cation and partnerships), development of standards and a provin-cial evaluation plan. A communication and engagement plan wasdeveloped that included the following: presentations to key AHSopinion leaders and executive; participation in zone-based CDMplanning processes to ensure alignment with the AHLP model;presentations at local, provincial and national conferences; devel-opment of public and provider-specific key messages and programdescriptions; and publication of “success stories” on the AHS in-ternal and external websites.

All 5 AHS zones have agreed to adopt the common provincialname, and zone-specific communication strategies have beendeveloped to aid in program branding with the AHLP name. Underthe AHLP banner, programs will have common referral criteria,consistent standards of care and a standard set of services (edu-cation, exercise and self-management). Evidence-informed carestandards, protocols and guidelines have been implemented for theself-management workshops, and are under development for theeducation and exercise services and diversity component. Thesestandards, protocols and guidelines will enable consistencyregardless of where the participant receives care, while providingprograms with the flexibility in how to apply and implement thestandards in their local communities.

Scalability

The deployment of the AHLP was built upon previous localsuccesses in establishing CDM services. The goal of AHLP is toexpand on these services to reach 80 additional communitiesacross Alberta, phased in over 4 years. Growth strategies haveincluded: partnerships with community, primary care and otherAHS service areas to leverage existing resources; expansion ofprogram eligibility and content by introducing specific diseases ina staged fashion according to local needs and program capacity;successful demonstration projects that supported reallocation offunds for sustainability; and modification of former service modelsto create additional capacity. Utilizing these methods, the programis highly scalable. Cost per patient in 2011 varied across zonesfrom $119 to $2034, with an average of $390/participant. Lowercosts were seen with programs that had higher volumes and wereless geographically dispersed. Program costs and progress towardsthe target volumes will be tracked through the provincial evalu-ation framework.

Outcomes

A provincial evaluation framework has been developed and isunder implementation to assess the impact of the AHLP on clinicalindicators, quality of life, self-efficacy, participant experience andhealth care utilization. While province-wide outcomes are not yetavailable, an initial evaluation of the same model in the Calgary

Zone CDM program (2008) indicates the potential system and pa-tient level outcomes that might be achieved across the provincewith the AHLP.

The Calgary Zone outcome evaluation included an analysisof consecutive participants who started the program betweenApril 2005 and April 2006, had a documented intake date in theprogram’s Information System, participated in any of the threeservice pillars (education, exercise and/or self-management) andattended at least 1 visit. Eligibility criteria for the programincluded age �18, presence of at least 1 self-reported chroniccondition, and physician approval to participate (for the exercisecomponent). This yielded a cohort of 2220 individuals, 60% female,with an average age 57 years. Self-reported chronic conditions, inorder of prevalence, were diabetes (47.5%), hypertension (38.4%),dyslipidemia (31.1%), chronic pain (23.2%), obesity (11.2%) andCOPD (7.9%). Program length varied according to which serviceswere accessed, and averaged 8 weeks. The primary analysisstrategy was a repeated measures cohort analysis. Repeatedmeasures included baseline, defined as the period 11 monthsprior to 1-month post first service contact, and follow up,defined as 6 to 18 months post first service contact (centred at1 year). The full follow-up period (i.e. 18. 18 months) must haveelapsed to include participants in the analysis. Retention ratesfor participants in the cohort was not available; however, theentire cohort was included at baseline and follow-up periods,with follow up being independent of retention as administrativeand laboratory data sets were used to access baseline and follow-up data.

Health care utilization in this cohort was assessed by exam-ining available administrative data on emergency department (ED)visits and in-patient (IP) admissions per 1000 patients. Theaverage visits and admissions in the baseline period and 1-yearfollow up were compared. Results reveal a significant 14.3%reduction in ED visits at follow up and a 63.7% reduction in EDvisits in higher risk clients (�2 ED visits in the year prior toparticipation). Likewise, for high-risk clients (�2 IP admissions inthe year prior to participation), a 75.4% reduction was observed inIP admissions at 1-year follow up. (Figure 4).

Clinical outcomes were assessed as changes in HemoglobinA1C (HbA1C) and in total cholesterol to HDL cholesterol ratio(T-chol:HDL) in participants with diabetes. Given multiple mea-sures for these indicators were available in some participants, theaverage of all available measures in the laboratory database forthe 12-month baseline and the 12-month follow-up periodswere compared using a repeated measures analysis. Significantimprovements were observed in HbA1C and T-chol:HDL at 1-yearfollow up in participants with diabetes. When higher-risk

Table 1Calgary Zone Program outcomes: baseline to 6 or 12 months

Variable IC CDM program population Mean level baseline F/U period (mos) Mean level F/U p < Effect size Cohen’s d

HbA1c (%) All with diabetesn¼730

7.63 12 7.38 0.001 0.38

High risk with diabetes (baseline HbA1C � 9.0%)n¼121

10.39 12 9.13 0.001 1.12

T-Chol:HDL All with diabetesn¼626

3.87 12 3.72 0.001 0.33

High risk with diabetes (baseline T-C:HDL � 5.0)n¼96

5.78 12 5.07 0.001 0.99

L. Morrin et al. / Can J Diabetes 37 (2013) 254e259 259

participants were analyzed separately, the absolute improvementand effect size was even greater (Table 1). Given the before-afterdesign, other explanations of findings (e.g. regression toward themean effects) are possible. However, these findings compare tothose reported in the literature for diabetes-specific self manage-ment and group education programs (16).

Challenges and Success Factors

Challenges to full implementation of the AHLP model haveincluded staff recruitment in remote and rural areas, competitionfor community space, absence or variation in electronic medicalrecords, limited funding to expand access, building effective part-nerships, coordinating care across the continuum and maintainingadequate flexibility to meet local needs while adhering to a com-mon standard of care.

Leaders and stakeholders have identified critical factors thathave contributed to the success of the provincial AHLP model,including:

� AHS as a single entity and leadership at the provincial and zonelevel to champion and support a province-wide approach toCDM;

� Evaluation of regional programs that have demonstrated suc-cess for the integrated approach, and going forward, a commonprovincial evaluation framework;

� Positive relationships, collaboration and partnerships with thezones, primary care and the community;

� Disease-spanning approach that has improved resource man-agement, reduced duplication in care, improved access andprovided a more patient-centric approach;

� Multimethod approach to program entry (physician/healthcare provider referred, self-referral, integration into carepathways) and champions within each specialty area to pro-mote the AHLP to support adequate participant recruitment;

� Common provincial name that has improved navigation anddemonstrated an integrated approach;

� Systematic assessment and prioritization of the needs ofdiverse and vulnerable populations across Alberta that has ledto targeted approaches to improve access for these groups.

In conclusion, the AHLP model has been successfully imple-mented in communities across Alberta. Initial results indicate thisapproach is associated with reduced acute care utilization and

improved clinical indicators, and achieves efficiencies through anintegrated, disease-spanning patient-centred approach. Commonstandards will reduce provincial variation in care, yet maintainsufficient flexibility to meet local and diverse needs and achieveequity in care.

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