8 Waterloo-Wellington FHTs in project to transform care for diabetes patients

Those with a chronic disease live with their condition every day – and even though they rely on the support of their healthcare team, they can feel isolated and alone. And when their condition pushes outside norms, they can feel confused and frightened.

Their healthcare team can also be hampered by a lack of information – on the current medical condition of their chronic disease patient and on their overall medical status – because they see the patient infrequently and because the patient’s medical record is often not available for sharing amongst team members.

A recently completed demonstration project in the Waterloo Wellington Local Health Integration Network (WWLHIN) sought to change all that.

“Chronic disease management is a growing concern for healthcare providers in Ontario and across the country,” said Glenn Holder, Chief Information Officer, WWLHIN. “That’s why our LHIN undertook HEALTHeCONNECTIONS, a two-year project to demonstrate the effectiveness of an eHealth-enhanced chronic disease management model tailored for patients living with diabetes.

“It really was all about the patients – improving their level of care by getting them actively involved in the management of their disease, giving them more control and understanding of their condition, giving them immediate access to their medical record and healthcare team – all through the convenience of their personal computer.”

The HEALTHeCONNECTIONS (HeC) Project began March 1, 2008 and ended September 30, 2010. During that period nearly 1,000 patients, and hundreds of healthcare practitioners participated. According to a recently completed Benefits Evaluation Report – and based on interviews with many of the participating patients and members of their healthcare teams – HeC more than achieved its overriding objective of improving patient care.

“The key element for me was the Health Portal for patients,” said physician-participant, Dr. Mohamed Alarakhia of the Centre for Family Medicine, Kitchener. “Diabetes is a very difficult disease to live with. It’s easy to let diabetes take control of you and of what you do – and it’s easy to be very overwhelmed.”

“The Health Portal is an online e-tool that allows patients to take back control. They are able to enter blood sugar readings and see how their actions allow them to control those readings. They are able to see trends over time. It allows them to learn more about their condition and therefore helps them improve their management and their confidence that they are able to manage this condition. It also improves communication with the healthcare team and that is very positive. I see this as the next logical step in patient care,” said Dr. Alarakhia.

“We typically see diabetes patients four times a year,” said Nurse Specialist, Kelley Eves of the Upper Grand River Family Health Team. “The Health Portal allows us to see what’s happening with them over the other 360 days of the year. Patients have a much better understanding of their condition and are much more engaged in managing it. We also see more general, positive lifestyle changes.”

In Ontario, more than 900,000 people are living with diabetes. Over the past 10 years, the number of Ontarians with diabetes increased 69 percent and is expected to grow to 1.2 million during 2010.

The WWLHIN is a provincial leader in the quality of its diabetes care. The HeC Project was an opportunity for the LHIN to demonstrate further improvements to quality of care and best practices by developing better integrated models of care and adopting eHealth-enabled technology that included a Health Portal for patients and their healthcare team and Clinician/Provider portal that allowed the online sharing of patient medical records.

“The Health Portal is really great,” said HeC Project participant Wayne Michalski, a Type 2 diabetes patient. “I am interested in maintaining good health for the rest of my life for my own benefit and for my family’s benefit. So when I started using this tool, I really liked it. It allows me to evaluate and measure my own health and to be responsible for my own health. It means fewer visits to the doctor and less cost for the people of Ontario for my health.”

Project Scope

HeC was a unique clinical transformation project with the overriding objective of improving patient care. It achieved that objective by:

• Establishing 4 Diabetes Care Networks within the WWLHIN boundaries that included 5 Diabetes Specialists, 4 Diabetes Education Centres (DECs), 6 Hospitals/Emergency Departments, 8 Family Health Teams of physicians and other healthcare professionals, and the Waterloo Wellington Community Care Access Centre

• Working with the Diabetes Care Networks to implement an eHealth enhanced model for diabetes care

• Deploying a Personal Health Record and Patient Portal to support the care model

• Enabling the sharing of patient provided data, and primary care provided data with the patient’s care team

• Enabling the sharing of acute care data by connecting WWLHIN acute care hospitals and key referral centres in the Hamilton Niagara Haldimand Brant LHIN

• Completing a Benefits Evaluation Program that reported on the benefits achieved through the enhanced care model and the use of a Personal Health Record and Health/Patient Portal

Project legacy

While a demonstration project, HeC’s significant legacy includes:

• A group of patients who are better managed and in better control of their diabetes

• Experience in creating multi-disciplinary healthcare teams/groups that cross traditional boundaries

• A foundation for new, better integrated models of care through the adoption of technology

• A foundation for sharing health information electronically across all healthcare providers (regardless of location) and with the patients themselves

Eight FHTs participated in the project: Minto Mapleton FHT; Mount Forest FHT; Upper Grand FHT; New Vision FHT (Kitchener-Waterloo); Centre for Family Medicine (Kitchener-Waterloo); Guelph FHT; East Wellington FHT; Two Rivers FHT (Cambridge)

Six Hospitals participated in the project: North Wellington Healthcare (includes Palmerston and Louise Marshall Hospital); Groves Memorial Community Hospital (Fergus); Grand River Hospital (Kitchener-Waterloo); St. Mary’s General Hospital (Kitchener-Waterloo); Cambridge Memorial Hospital; Guelph General Hospital

Three DECs participated in the project: Wellington Healthcare Alliance Diabetes Education Centre (includes locations at Palmerston, Louise Marshall, and Groves Memorial sites); Grand River Diabetes Education Centre (located within Grand River Hospital); Diabetes Care Guelph (program is located within the Guelph FHT)

The HeC Project was a two-year WWLHIN clinical transformation demonstration project sponsored by Canada Health Infoway under its Patient Access to Quality Care (PAQC) program and the Ontario Ministry of Health and Long Term Care (MOHLTC) eHealth Program. In addition:

• Practice Solutions (a Canadian Medical Association – CMA – company) provided the mydoctor.ca Health/Patient Portal.

• Hamilton Health Sciences Corporation provided the ClinicalConnect component.

• SaskTel provided the LifeStat Remote Patient Monitoring system (which allowed a subset of patient participants from the Guelph Family Health Team (FHT) to automatically upload glucometer readings into the Health/Patient Portal.

Story posted from Canadian Healthcare Technology eMessenger –December 2, 2010

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