A change concept is a general idea or approach that can be customized into a specific change idea to be tested in your own setting. Our Chronic Disease Management (CDM) change concepts have been organized by the elements of Ontario’s Chronic Disease Prevention and Management
(CDPM) Framework; some ideas may belong in more than one element of the framework. The ideas here are intended to b e a “menu” of things to consider. It is not intended to be a complete list and teams will discover other change concepts during the improvement journey. After you choose concepts to work on, tailor the idea to your situation and test using QI methodology.
Healthy Public Policy ............................................................................................................................ 2
Community Action ............................................................................................................................... 2
Supportive Environments .................................................................................................................... 2
Health Care Organizations ................................................................................................................... 3
Personal Skills and Self-Management Support .................................................................................... 3
Delivery System Design ........................................................................................................................ 4
Provider Decision Support ................................................................................................................... 5
Information System ............................................................................................................................. 5

Public policy refers to legislation, regulation, administrative and organizational policies. The development and promotion of healthy public policies are a shared responsibility of individuals, communities, the private sector and governments.
Examples of Change Ideas:
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Invite a speaker to a team or board meeting to increase awareness of social determinants of health and health inequities.
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Test policy to offer all programs and services at no cost to patients/clients.
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As a group, write a letter to the editor about a health inequity concern.
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Share your experience of how policy affects health with community advocacy groups.
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Developing and implementing organizational policies to support a healthy workplace for staff and genuinely accessible programs and services for patients/clients.
Through partnerships across all sectors, communities participate and collaborate to enhance knowledge, skills and resources to increase control over the issu es that affect the patient’s health.
Communities that take effective action on issues to improve their populations’ health will be healthier places.
Examples of Change Ideas:
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Form linkages/partnerships with community organizations to support or develop programs for individuals with chronic illness.
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Advocate for policies and programs to improve care in the community.
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Encourage patients with chronic illness to participate in effective programs, community education classes and support groups that would be beneficial to them.
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Raise community awareness through networking, outreach and education.
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Provide education/event calendar and list of resources to patients and their families (e.g., public health smoking cessation programs, CCAC, local recreation facilities, rehab, PT, etc.)
 Realign the organization’s diabetes education with that of local diabetic education centres
(DECs) to increase collaboration and sharing of resources.
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Partner with local pharmacists and other healthcare providers regarding chronic illness care processes.
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Explore opportunities for secondary prevention strategies for individuals living with a chronic illness.
Supportive environments are living and working conditions that promote health and prevent chronic disease by being stable secure and safe, as well as being stimulating, satisfying and enjoyable.
Creating these conditions enable individuals to make healthy choices.
Examples of Change Ideas:
2 Change Concepts Health Quality Ontario

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Develop tools and processes to ensure patients/clients are asked about living conditions
(e.g., isolation, transportation, housing, income and multicultural issues) through tools such as customized flow sheets/stamps.
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Revised health information to ensure it is culturally appropriate.
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If appropriate, refer patients to programs and services for marginalized populations (e.g.,
Good Food Box, Collective Kitchens, or multicultural seniors programs).
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Collect data on patient/client experience on which to base change ideas.
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Offer space to local diabetes education centre to bring diabetes support on-site.
The Healthcare Organization champions change through strong leadership, aligning resources and incentives, and committing to quality improvement (QI) and accountability for outcomes. The organization shifts from reactive, episodic acute care to proactive chronic disease prevention and management.
Examples of Change Ideas:
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Build a culture of quality improvement and integrating QI with CDPM.
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Includ e ‘improving chronic illness care’ as part of the organization’s vision, mission, goals and quality improvement plans.
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Establish measureable goals for chronic illness care in the business plan.
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Senior leaders and staff visibly support and promote improvement in chronic illness care.
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Regularly update the Board/Executive/Directors regarding QI work.
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Recruit staff whose values align with the values and culture of the organization and ensuring policies and job descriptions align.
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Frequently update job descriptions as roles are optimized.
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Support the QI team by establishing regular team meetings, removing barriers, and providing necessary resources.
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Use effective improvement strategies aimed at comprehensive system level changes.
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Include regular 5-minute QI team updates in board meetings.
 Include ‘QI Corner’ updates in the organization’s newsletter.
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Create and establish policies/protocols for new chronic illness care processes.
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Establish monthly meetings with the QI team (including agenda, minutes).
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Create and update a QI communication bulletin board display for the entire organization to review.
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Emphasize patient-centred and organizational philosophies in job postings for new positions.
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Plan for sustainability and spread.
Patients with chronic conditions set their personal action plans, make decisions about their care and develop problem solving skills that help them reach their targets for good disease control. This is done in collaboration with the patient's health care provider team.
Examples of Change Idea:
Health Quality Ontario Change Concepts 3

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Build a culture where the patient is a partner, and where the patient has a central role in the prevention and management of their illness.
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Create a shared care plan with the patient.
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Giving patients copies of their flow sheets, run charts at each visit.
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Encourage patients to use peer support groups for their chronic disease, such as those offered by the Canadian Diabetes Association.
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Use every staff interaction with patients as opportunities to reinforce patient selfmanagement goal setting and practices.
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Establish written action plans or self-management tools (e.g., passport).
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Tracking and follow-up of self-management goals in electronic medical records (EMR) or electronic health records (EHR).
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Assess patient self-management knowledge, behaviours, confidence and barriers.
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Tap into community resources to achieve self- management goals.
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Review and tailor patient education documents to meet their literacy needs.
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Use group visits to support self-management.
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Utilize teach-back methods to ensure patient understanding and engagement.
Patient care is well designed in advance of the patient visit to ensure patient issues are reviewed systematically and regularly. Visits are conducted in an organized rather than haphazard fashion.
Examples of Change Ideas:
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Design the delivery of care through the eyes of the patient (reduce waste, from the patient's perspective).
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Use daily huddles.
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Incorporate evidence-based care.
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Determine who and how care is provided, with well-defined roles.
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Maximize team members ’ capacity within their scope of practice.
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Develop effective case management functionality into the practice.
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Ensure continuity of care within and across care team; including regular follow-ups by a variety of methods such as outreach, phone calls, email, home visits, etc.
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Explore how care could be delivered (e.g., planned visits, group visits, telephone follow-up):
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Max-pack a visit using evidence-based care.
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Periodic planned prepared visits for complete review of all critical items for disease management.
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Create protocols for insulin, Coumadin, and other medications requiring frequent dose adjustments.
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Create checklists to review care delivery.
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Establish group visits with clinician and patients with similar health problems.
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Identify a leader within practice with special interest in a particular chronic condition.
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Use home care to assist with home monitoring or patient self-management.
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Improve coordination between hospital and community based family practice during discharge planning.
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Map the chronic illness patient journey.
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Telephone and/or email follow-ups.
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Allow nurses to play a more prominent role in chronic illness care/visits.
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Book follow-up visits for chronic illness patients as part of routine.
4 Change Concepts Health Quality Ontario

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Have patients taking their own BP prior to their appointment.
Health providers use tools to help them decide on the best treatment options for patients, or as reminders for prevention and management guidelines.
Examples of Changes Ideas:
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Build a reminder system for physician to flag patients not in control of disease or not on right medication.
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Use evidence-based guidelines in patient care.
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Provide patient-related guidelines and information during patient visits (e.g., passports with patient- tracking labs and self-management plan).
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Consult and collaborating with specialists.
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Incorporate team education and training.
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Use of flow sheets, alerts and screening tools.
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Use of EMR/EHR to alert team of drug interactions.
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Collaborate with specialists to create processes for timely referrals (e.g., referral form and process for consultations).
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Inform patients about guidelines and relevant materials pertinent to their care at the time of their visit (e.g., passports).
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Use proven healthcare provider education modalities in support of chronic illness improvement.
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Train primary care team on the application and interpretation of evidence informed practice guidelines to set standards of care.
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Prepare for the patient visit by reviewing their current health status, goals, milestones and accomplishments.
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Screen daily appointments for patients eligible for preventive care.
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Determine depression risk with clients.
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Develop and implement standing orders for the nurse e.g. urinary tract infection.
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Partner with local pharmacist and other health care providers regarding chronic illness care processes.
These systems tell health care providers who their chronic disease patients are and the quality of care they are receiving at any moment in time. With this information providers can get instant feedback on how well they are doing and more easily identify areas for improvement.
Examples of Change Ideas:
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Use an EMR/EHR to: o Develop patient registries. o Extract reports for key indicators. o Generate run charts. o Build reminders and follow-up prompts for providers and patients with chronic illness.
Health Quality Ontario Change Concepts 5

o Use alerts to develop proactive planned care. o Identify sub-populations of patients in order to better manage their care.
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Individual care planning.
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Facilitate collaboration among team members by integrating patient services.
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Track Clinical Practice Guideline performance.
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Print relevant information and give to patients to improve self-management.
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Establish a registry with standardized data entry to ensure data integrity.
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Generate reports on patients with chronic illness.
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Identify relevant patient sub-groups and provide proactive care.
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Develop and standardizing a problem list.
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Standardize documentation of diagnosis in problem list.
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Share information with others within the organization for continuity of care.
6 Change Concepts Health Quality Ontario