Home Is Where the Health Is: Advancing Team-Based Care in Chronic Disease Management

2009 ◽  
Vol 169 (21) ◽  
pp. 1945 ◽  
Keyword(s):  
Chronic Disease ◽  
Disease Management ◽  
Chronic Disease Management ◽  
Team Based Care

scholarly journals A Framework to Support the Progressive Implementation of Integrated Team-based Care for the Management of Copd: a Collective Case Study

2022 ◽  
Author(s):  
Shannon L. Sibbald ◽  
Vaidehi Misra ◽  
Madelyn daSilva ◽  
Christopher Licskai
Keyword(s):  
Primary Care ◽  
Chronic Disease ◽  
Disease Management ◽  
Chronic Disease Management ◽  
Scale Up ◽  
Collective Case Study ◽  
Widespread Agreement ◽  
Team Based Care ◽  
Integrated Team

Abstract Background: In Canada, there is widespread agreement about the need for integrated models of team-based care. However, there is less agreement on how to support the scale-up and spread of successful models; there is limited empirical evidence to support this process in chronic disease management. We studied the supporting, and mitigating factors required to successfully implement and scale-up an integrated model of team-based care in primary care.Methods: We conducted a collective case study using multiple methods of data collection including interviews, document analysis, living documents, and a focus group. Our study explored a team-based model of care for chronic obstructive pulmonary disease (COPD) known as Best Care COPD (BCC) that has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants included healthcare providers involved in the delivery of the BCC program. Results: We identified several mechanisms influencing the scale-up and spread of BCC and categorized them as Foundational (e.g., evidence-based program, readiness to implement, peer-led implementation team), Transformative (adaptive process, empowerment and collaboration, embedded evaluation), and Enabling Mechanisms (provider training, administrative support, role clarity, patient outcomes). Based on these results, we developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management. Our framework builds off our empirical work and is framed by local contextual factors. Conclusions: This study explores the implementation and spread of integrated team-based care in a primary care setting. Despite the study’s focus on COPD, we believe the findings can be applied in other chronic disease contexts. We provide a framework to support the progressive implementation of integrated team-based care for chronic disease management.

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