Champlain Local Health Integration Network
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Diabetes and Other Chronic Diseases

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

Through engaging the community locally, we seek to identify means that will encourage healthy living, support best practice management of complex conditions along the continuum of care - from prevention and early detection to the end of life.

The Champlain LHIN is working with our partners to improve chronic disease prevention and management in our region through the following initiatives:

• Baseline Diabetes Dataset Initiative 

• Video on Diabetes in the Champlain LHIN 

• Champlain Diabetes Services 

 • Chronic Disease Self-Management Programs

• Cardiovascular Disease Prevention Strategy

• Champlain Diabetes Strategy

• Champlain Regional Renal Program  

Chronic Disease Prevention and Management Collaborative 

Baseline Diabetes Dataset Initiative

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 to participating primary health providers across the province in Summer / Fall 2012.

Since its inception in May 2010, more than 6,300 primary care providers have joined the initiative and received Diabetes Testing Report listing testing dates for three key diabetes tests (blood glucose, cholesterol, retinal eye exam) for more than 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/diabetes, or by calling toll-free 1.800.291.1405 (TTY: 1.800.387.5559).  

Diabetes Screening Among Diverse Communities 

People with diabetes are a priority population for the Champlain LHIN. To learn more about the Champlain Diabetes SCREEN project for immigrant populations, take a look at our latest video:

Champlain Diabetes Services

The coordination of diabetes services in the Champlain region is now under the purview of the Champlain Local Health Integration Network (LHIN).

The Champlain Diabetes Services website has useful information on how to improve diabetes care in our region.

For more information about diabetes services in our region, contact Pierre Boulay, Lead, Diabetes/Vascular Health at pierre.boulay@lhins.on.ca 

Chronic Disease Self- Management Programs

Chronic disease self-management (CDSM) is a key component to improving health of people living with chronic conditions.  Since 2008, the Champlain LHIN has been investing in programs to support CDSM in three key areas:

• Self-management supports, programs and resources for chronic disease sufferers

• Education and support to health service providers

• Evaluation to determine whether the programs are making a difference in people’s lives as they manage their chronic conditions and to continually improve our programs.

Living Healthy Champlain is a coordinated effort among Bruyère Continuing Care (Bruyère, Élisabeth Bruyère Research Institute), the Champlain Community Care Access Centre (CCAC) and over 30 partner organizations to promote and facilitate chronic disease self-management programs and supports across the Champlain LHIN. For more information and to find a program near you, visit Living Healthy Champlain. To learn more about the Champlain CDSM Program, contact Rachel Bowen, CDSM Project Coordinator at Rbowen@bruyere.org. 

Living Healthy Champlain – A Year in Review

Living Healthy Champlain - workshop group shot• 30+ organizations work in partnership to deliver CDSM programs

• 50 CDSM workshops were offered in our region with 500+ participants

• Workshops offered in six languages (English, French, Arabic, Chinese, Hindi, Vietnamese)

• Knowledge transfer activities with 350+ health care providers in Champlain

• Evaluation activities are underway through focus groups with program participants

• Numerous conference presentations were given in Ontario, Canada, and the U.S.

Photo (L to R): Self-Management Program participants, Jeff Irven, Donna Lee Holley,
Sylvia S. Stojek-Martin and facilitators Anne Viljoen and Angela Cassell.

Cardiovascular Disease Prevention Strategy 

The Champlain Cardiovascular Disease Prevention Network is leading the implementation of a five-year Cardiovascular Disease Prevention Strategy within the Champlain region

This Strategy seeks to:

1) reduce the burden of heart disease and stroke; and

2) ensure the residents of the Champlain region are the most heart healthy and stroke-free in Canada.

Health care and community partners in primary and specialty care, public health, community health, and research settings from across the Champlain region have designed and are implementing six key population health initiatives in our region:

1) Smoking Cessation Network

2)  “Give Your Head a Shake” Sodium Reduction Campaign 

3) Healthy School Aged Children Initiative 

4) Get with the Guidelines Initiative 

5) Improved Delivery of Cardiovascular Care (IDOCC) 

6) Community Heart Health Survey 

Champlain Diabetes StrategyStand up to Diabetes

As in the rest of the province and Canada, diabetes is a large and growing health problem in the Champlain region.  In July 2008, the Ontario Ministry of Health and Long-Term Care (MOHLTC) announced a four-year commitment to an Ontario Diabetes Strategy.  The goal is to improve the health of Ontarians living with diabetes.  For more information on diabetes resources, please visit the Stand Up to Diabetes site.

The Champlain LHIN is working with our partners to implement changes necessary to improve diabetes care and services in our region.  People with pre-diabetes and diabetes are a population-of-focus for the Champlain LHIN over the next three years, as explained in our strategic plan, the  Champlain Integrated Health Service Plan 2010-2013.

Diabetes: Canada at the Tipping Point - Report by the Canadian Diabetes Association
Diabetes Education Programs

During the past two years, the Champlain region received seven new diabetes education teams to improve access to diabetes education in communities of highest need.  The new diabetes education teams are funded by the Ministry of Health and Long-Term Care located in

• Ottawa

• Eastern Counties 

• Cornwall

• Renfrew County

• Aboriginal communities (Akwasesne and the Wabano Centre for Aboriginal Health).

Diabetes Projects for High Risk Populations

Improving Care for Women with Gestational Diabetes - Led by Dr. Erin Keely, Chief Endocrinology and Metabolism at The Ottawa Hospital, work is underway to improve standardized screening and care for women with gestational diabetes.  For more information, contact ekeely@ottawahospital.on.ca

Outreach to High Risk Immigrant Communities - This project is set to engage high risk immigrant populations in addressing language and cultural barriers to improve access to diabetes education in Ottawa.  This project is led by Dr. Kevin Pottie, Family Physician, Principal Scientist at the Institute of Population Health, University of Ottawa and Co-chair of the Canadian Collaboration for Immigrant and Refugee Health (CCIRH).  For more information, contact kpottie@uottawa.ca 

Champlain Regional Diabetes Advisory Committee 

The Champlain Regional Diabetes Strategy Advisory Committee advises the LHIN and the Diabetes Regional Coordinating Centre on ways to improve the health system for people with pre-diabetes and diabetes.  This committee is comprised of a broad range of health care providers from across the region.

Champlain Regional Renal Program

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.

Renal services and dialysis planning is advised by the Champlain Regional Renal Committee led by Administrative Director, Connie Twolan ctwolan@ottawahospital.on.ca  and Clinical Director,

Dr. Peter Magner. The committee is working toward the goals of the ORN:

  • Prevent of delay the need for dialysis
  • Broaden appropriate chronic kidney disease patient care options
  • Improve the quality of all stages of chronic kidney disease care.

Nephrology Newsletter Spring 2011

Chronic Disease Prevention and Management Collaborative

In 2008, A Chronic Disease Prevention Management (CDPM) Collaborative was formed to provide a forum for knowledge exchange and innovation among key Champlain CDPM Community of Practice Networks (including networks that work in cardiovascular disease, stroke, diabetes, cancer, lung health, chronic kidney disease and others). These key networks meet to:

• Exchange ideas, information and quality improvement learning

• Identify and support areas of collaboration along the continuum of care.

Chronic disease self-management has been an important priority for this group and physical activity is an emerging focus.   For more information, contact Karen Patzer, Champlain LHIN Senior Planning & Engagement Specialist, Lead Diabetes at karen.patzer@lhins.on.ca.
 

Background documents:

Literature Review (26 pages)

Executive Summary  Literature Review (4 pages)

Environmental Scan