Entete 3

Adaptation, implementation and evaluation of an intervention involving the integration of chronic disease rehabilitation services into primary care

(Funded by: Pfizer-FRSQ-MSSS Chronic Disease Fund)

 By Martin Fortin and Maud-Christine Chouinard


Aging is associated with an increasing number of chronic diseases (CD) which represents a challenge for the healthcare system [1-2]. While traditional health care funding and management are mainly designed to address acute health conditions, the bulk of health funds is allocated to patients with CD [3]. The Chronic Care Model (CCM) suggested a multi-component remodeling of CD services to improve patient outcomes [4]. To meet the complex and ongoing needs of patients with CD, rehabilitation has been advocated as a key feature of primary care [5]. Moreover, patients with multimorbidity represent a greater challenge to primary healthcare as they are associated with high healthcare costs and poor compliance to treatment and recommendations [6-7]. In the presence of multimorbidity, health care providers acting in primary care face difficulties in applying guidelines and in maintaining continuity of care. To prevent potential health care system gaps in quality, efficiency, and effectiveness, primary care physicians have to play a gatekeeping role in the management of multimorbid patients and should be assisted in CCM integration and application. Consequently, decision makers and physicians have to look to evidence-based practice guidelines to improve the quality of care and to manage the allocation of resources as efficiently as possible[8].

In this regard, we aim to establish a clinical intervention that will adapt and permanently integrate rehabilitation services into primary care settings and to develop objective tools to assess the adaptation and implementation of this intervention in eight primary care practices in the Saguenay region (Quebec, Canada), in order to ensure the sustainability of interventions beyond the rehabilitation period. More specifically, the intervention will aim to clinically operationalize the mechanisms and tools necessary for the delivery of integrated CD services, promoting continuity of care in response to the needs expressed by stakeholders and to deploy rehabilitation services adapted to the realities of various primary care settings.

The evaluation of the implementation will be conducted using descriptive qualitative methods, while the evaluation of the effects will be based on a combination of experimental designs: randomized trial using a delayed intervention arm (n=326), a before and after design with repeated measures (n=163), and a quasi-experimental design using a comparative cohort (n=326). The qualitative evaluation will be based on focus groups and individual interviews before, during and after the implementation with various stakeholders (decision makers, primary care professionals, rehabilitation professionals and patients). Assessment of effects on patients will use self-administered questionnaires measuring chronic disease self-efficacy, health education impacts, health behaviors, quality of life, and psychological well-being.

Patients included in this study will be referred by their primary care provider and have to present at least one of the conditions for which rehabilitation is currently available (or their risk factors): diabetes, cardiovascular diseases, COPD, asthma. Total disease burden will be assessed for each patient. Data collected from participants will be analyzed in three steps according to a qualitative content analysis procedure to identify emerging themes and trends: coding, sorting of text content and analysis. In addition, the analysis will focus on shedding light on: (1) the interaction between the implementation context and the intervention on the effects obtained; (2) contextual determinants of the changes that occurred from various perspectives on organizational change, including political, structural, psychological and organizational models.

In the short-term, we are expecting improved patient self-efficacy, empowerment and self-management. In the long-term, this should result in a reduction of their risk factors, with an improvement in quality of life and psychological distress. At the organization level, the project should lead to a coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration.

Multimorbidity represents a crucial step in the process of adaptation of evidence-based medicine to the primary care reality. Among patients with CD, those presenting multimorbidity show high levels of health care utilization. It is important to increase our understanding of primary care needs in rehabilitation services and the characteristics of conceptual models of interventional approaches designed for patients followed up by family physicians. In conclusion, the integration of specialized rehabilitation services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated.

1. Fried, L.P., Epidemiology of aging. Epidemiol Rev, 2000. 22(1): p. 95-106.
2. WHO, Chronic disease risk factors. 2003.
3. Mirolla, M., The cost of chronic disease in Canada The Chronic Disease Prevention Alliance of Canada, 2008.
4. Wagner, E.H., et al., Improving chronic illness care: translating evidence into action. Health Aff (Millwood), 2001. 20(6): p. 64-78.
5. McColl, M.A., Structural determinants of access to health services for people with disabilities. Disability and social policy in Canada. 2nd ed.. Toronto: Captus Pr;, 2006: p. 293–313.
6. DiMatteo, M.R., et al., Patient adherence and medical treatment outcomes: a meta-analysis. Med Care, 2002. 40(9): p. 794-811.
7. Hughes, C.M., Medication non-adherence in the elderly: how big is the problem? Drugs Aging, 2004. 21(12): p. 793-811.
8. Wagner, E.H., B.T. Austin, and M. Von Korff, Organizing care for patients with chronic illness. Milbank Q, 1996. 74(4): p. 511-44.

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