Integration of Chronic Disease Rehabilitation Services Into Primary Care
Condition: Cardiovascular Disease; Heart Failure; Chronic Obstructive Pulmonary Disease; Asthma; Diabetes
MeSH terms: Lung Diseases, Obstructive; Pulmonary Disease, Chronic Obstructive; Cardiovascular Diseases; Chronic Disease
Study type: Interventional

Summary: 
      The aim of PR1MaC is to establish a clinical intervention that will adapt and permanently
      integrate rehabilitation services into primary care settings, which would be the reference
      point in the health care system for people with Chronic diseases (CD). More specifically, the
      intervention will aim to: (1) clinically operationalize the mechanisms and tools necessary
      for delivery of integrated CD services, promoting continuity of care in response to the needs
      expressed by stakeholders; (2) implement and deploy rehabilitation services adapted to the
      realities of various clinical primary care settings and develop tools to ensure the
      sustainability of interventions beyond the rehabilitation period; and (3) support clinical
      primary care teams in the acquisition and maintenance of evidence-based practices for the
      targeted CDs.
    

Detailed description: 
      Since 2001, professionals in the Saguenay-Lac-Saint-Jean (SLSJ) region in Quebec province,
      Canada, have been mobilized to deal with the challenges of CD management by the introduction
      of the SLSJ Trajectory of Integrated Rehabilitation Services for CD (Trajectoire des services
      de réadaptation intégrés pour MC du SLSJ), hereafter referred to as the "Trajectoire." This
      Trajectoire, deployed across the region, constitutes a solid network of rehabilitation
      services, due as much to the resources granted to it and its evidence-based approach as to
      the appreciation that patients and professionals within the regional health system have for
      it. The changes and new directions that have taken place in recent years suggest it is time
      to improve this Trajectoire by promoting greater integration with primary care services to
      improve accessibility, the complementarity of services and better post-rehabilitation
      continuity. The proposed intervention involves the adaptation and integration of
      rehabilitation services under the Trajectoire's leadership within primary care settings (FMG
      or medical clinics), so that collaborative work routines are developed and implemented
      directly at the main place of contact with health services for people with a CD. The
      intervention will be implemented at the CSSSs in Chicoutimi and Jonquière. This logic model
      was developed in collaboration with researchers, clinicians and decision-makers involved in
      this application and discussed at meetings for the preparation of this application. The
      model's first component (objective 1) will consist of a consultation with stakeholders
      (primary care professionals, Trajectoire professionals) by sharing information about the
      current range of services. In each area, the consultation will include a needs evaluation and
      a reflection on the Trajectoire's services that can be adapted for targeted clients. As each
      clinic where an intervention will be deployed has its own mode of operation and clientele
      characteristics, the clinical intervention will be specifically adapted to these
      considerations and prepared in collaboration with each clinical setting to ensure a range of
      services that meets the expressed needs.

      The second component (objective 2) will be to implement and deploy a range of concerted
      interdisciplinary services adapted to the client services and professional resources already
      in place. Services that do not require specialized equipment or adapted premises (a gym, for
      example) can be integrated, including educational/teaching services (self-care, support to
      stop smoking, nutrition, etc.). In medical clinics currently not offering these services, the
      addition will be net, while in those that already rely on the services of nurse practitioners
      (FMG), the addition of these services will complement existing services. During this period,
      various mechanisms and clinical information sharing tools will be implemented jointly by
      professionals. The third component will be to implement a support mechanism and ongoing
      evaluation within the clinical setting to ensure harmonious integration. If necessary,
      training workshops will be provided to implement or maintain evidence-based practices and to
      plan longer-term follow-up of clientele and continuity of interventions.

      The intervention: (a) will be educational in nature, patient-centred and based on the
      Trajectoire; (b) will last at least three months and involve at least three meetings; (c) may
      include meetings with small patient groups or the involvement of a close relative of the
      patient (spouse or primary caregiver); (d) will be carried out based on a referral from the
      primary care team according to defined criteria; (e) will allow an exchange with the primary
      care team and will be integrated into the primary care medical records; (f) will provide for
      a transfer of responsibility to the primary care team to ensure ongoing long-term follow-up.
    

Intervention name(s): Support, management, educational, counselling, follow-up
Intervention type(s): Behavioral
Intervention description(s): The project offers a range of activities (educational, counselling, follow-up) by several professionals. The varied range of services is spread out over six months and may include individual or group meetings with professionals. Informational documents and follow-up tools are provided to patients based on their condition, to facilitate the acquisition and maintenance of knowledge, self-management, and changes in risk behaviour.
Other intervention name(s): dietetics, respiratory therapy, smoking cessation, physical activity, Stress management, Psychosocial support, Drug compliance
Allocation: Non-Randomized
Intervention model: Factorial Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: Chronic diseases; Primary care; Rehabilitation; Chronic Care Model; Patient centered medical home