Supporting you
to take control of
your health
Living Healthy
Champlain
Annual Report
2010/11
self
manage
ment
support
GOAL
The overarching goal of Living Healthy Champlain is to
provide people with chronic disease(s), their families
and/or caregivers with self-management capacity to better
manage their health.
OBJECTIVE
The objectives of Living Healthy Champlain are to
improve and sustain patient self care and self-management
support in the Champlain LHIN
STRATEGIC DIRECTION
Achieve objective through:
1) Facilitating co-ordination of and access to selfmanagement supports, programs and resources for
people with chronic conditions;
2) Developing a culture of self-management support for
patients, providers, and communities across the
Champlain region; and
3) Evaluating reach, effect of strategies and investments.
"I think the big thing of the
program was discovering people
that knew exactly how you felt."
1
MESSAGE FROM THE CHRONIC DISEASE SELF-MANAGEMENT
STEERING COMMITTEE
On behalf of the entire Living Healthy Champlain team, we would like to extend a very
heartfelt thank you to all of our partners for helping us achieve our vision of providing
people with chronic disease(s), their families and/or caregivers with self-management
capacity to better manage their health.
Each year we are increasingly happy to see health care providers working collaboratively
towards a shared goal, and it is this compassion and dedication that drives us to continue
facilitating learning and self care management.
We are especially grateful to our funding partner, the Champlain LHIN, and our other
collaborators, the Champlain CCAC, Élisabeth Bruyère Research Institute and Bruyère
Continuing Care for all of their continued dedication in supporting chronic disease selfmanagement initiatives. With their prospective and long-term vision we have achieved great
milestones in a short amount of time. It has been a wonderful working relationship which
we look forward to continuing into the future.
We continue to believe strongly in the principles of self management and the power that
these techniques and skills can bring to individuals and to caregivers, and to the overall
health of our region and healthcare system. We look forward to the next year of the
program.
Living Healthy Champlain encourages all to continue on the journey of incorporating selfmanagement into your life, and we will continue to practice and proclaim our motto:
Supporting you to take control of your health!
Debbie McGregor,
Steering Committee Chair
2
… it was to me a plus to me to
meet people…I always learn
something from other people and
how they’re coping, or little
things, little nuggets that they
have recommended that you think
“Oh I haven’t thought of that”.
INTRODUCTION
In 2008 Dr. Clare Liddy, Dr. Sharon Johnston, and Sarah Mae Ives, Outreach Coordinator,
completed a literature review and an environmental scan gaining health care providers’
perspective on Chronic Disease Self-Management Support in the Champlain LHIN. The
results of this work, entitled Self-Management Support: A New Approach Still Anchored in
an Old Model of Care, has been published in the January/February 2011 edition of the
Canadian Journal of Public Health (available online at http://journal.cpha.ca/
index.php/cjph/issue/current). Following this work and with support and funding from the
Champlain LHIN, Living Healthy Champlain was created!
Living Healthy Champlain (LHC) is a coordinated effort between Élisabeth Bruyère
Research Institute (ÉBRI), Bruyère Continuing Care (Bruyère) and the Champlain
Community Care Access Centre (CCAC) with the Champlain Local Health Integration
Network (LHIN) as funding partner. This two–year project funded by the Champlain
LHIN through 2009/2010 and 2010/2011 has brought the partner
organizations together to coordinate, promote and facilitate chronic
What is self-management?
disease self-management programs across the Champlain LHIN.
In the Champlain region, there are over 400,000 individuals with a
chronic disease1. The specific patient population which can benefit from
this regional coordination includes adults living with one or more chronic
health conditions including, but not limited to, diabetes, arthritis, chronic
pain, neurological conditions, renal disease, respiratory conditions,
cardiovascular disease and mental health illnesses. The program aims to
reach a minimum of 1,000 participants per year.
…the active participation of
individuals in achieving their
best health and wellness. This
involves gaining the
confidence, knowledge and
skills to manage physical,
social and emotional aspects
of life in partnership with
health care teams and
community supports.
Living Healthy Champlain provides information, training and resources
for health service providers who are currently engaged in providing
(ODS Self-Management Working
Group, August 2010)
chronic disease self-management (CDSM) programs, as well as those
individuals and/or organizations that are interested
and have the capacity to start programs. To date,
What is self-management
there are 31 organizations who are engaged at varying levels in
support?
providing Chronic Disease Self Management training programs
… a range of organizational,
for residents of Champlain. LHC supports these organizations by
community and provider
providing training and resources for health care professionals
strategies to support the active
engaging in self management strategies, helping to identify and
participation of individuals in
train volunteer peer leaders, and is developing volunteer support
achieving their best health
systems to provide ongoing leadership and training for volunteers.
and wellness.
(ODS Self-Management Working
Group, August 2010)
Partner Organizations & Volunteers
Our partner organizations and the individuals are the key
1
3
Bains et al., 2007
ingredient in our recipe for success. They dedicate time, resources, space, and share
knowledge and experience with LHC. They are the main source for insights on
improvements to the program, next steps for self-management supports, linkages to
community events and resources and many other facets as well. All of our training
sessions are facilitated by leaders who volunteer four full days of time to complete these
sessions. We thank both the leaders and the organizations that support them for their
hard work and dedication. For a list of LHC’s partner organizations, please see Section 2.
Self-Management Support
LHC offers training in several different self-management support strategies, including:
 Stanford “Living a Healthy Life with Chronic Conditions” group-based
workshop
 Motivational Interviewing
 Health Coaching Peer for Progress (Diabetes)
 Health Coaching Australia
 Behaviour Change & Modification
 Diabetes Conversation Maps ™
All of these programs encourage and nurture individuals to maintain their best possible
health, harnessing their own skills and abilities and strengths.
Sustainability is a frequently heard word amongst the LHC team, and this is kept in mind
throughout all endeavours. To support sustainability, LHC holds recurrent Community
Leadership meetings to bring together all trained volunteers and health professionals for
feedback, knowledge transfer, networking and brainstorming. These meetings aim to reengage LHC partners and provide updates on self-management information and events.
Three of these successful events were held in the 2010/11 year.
LIVING HEALTHY CHAMPLAIN TEAM
Dr. Sharon Johnston
Principal Investigator
4
Dr. Clare Liddy
Principal Investigator
Erin Rae
Regional Coordinator
Hannah Irving
Evaluation Coordinator
Sarah Mae Ives
Outreach Coordinator
Sophie Des Rosiers
Program Assistant
Karina Mill
Jr. Research Asst
OBJECTIVE 1: FACILITATING CO-ORDINATION OF AND ACCESS
TO SELF-MANAGEMENT SUPPORTS
Geographical Reach
The burgundy stars indicate where group (Stanford) workshops are currently being offered.
There is a concentration of red stars in the Ottawa region, as workshop locations cannot be
accurately placed on a map this size. From this depiction, LHC has
identified a few areas to focus on in the coming months:
“Because you are lost, you as
a patient are lost, you don’t
know how to go about it. “
5



Eastern Counties: Hawkesbury, Casselman, Rockland
Lanark: Almonte, Carleton Place, Arnprior
Renfrew County: Deep River
Project Deliverables
The following chart provides a visual representation of our target goals, and the actual
numbers achieved since project inception. The Providers column indicates our
knowledge transfer activities. Participants are those who have taken group-based selfmanagement, Volunteers include all peer leaders trained in the group-based program.
Finally, Workshops are what LHC identifies as group-based self-management
programs.
Project Targets & Totals for Groups
1100
1000
1000
900
800
700
768
600
600
600
Total
500
Target
400
300
200
62
100
80
57
85
0
Providers
Participants
Volunteers
Workshops
Some of the totals are below target, and this comes as no surprise to the team at LHC.
The targets set were ambitious, and are still something to strive for. However,
recognizing the population we are reaching can have complicated health problems,
attrition rates (approximately 20%) are a common occurrence within workshops.
Living Healthy Champlain will continue their goal of improving
access to self-management and self-management supports for all
“More determination…To
residents of the Champlain LHIN.
deal with the problem,
whatever it took, exercising
you know, whatever it
took…I think that’s the
greatest impact”
6
PARTICIPANT FEEDBACK
7
OBJECTIVE 2: DEVELOPING A CULTURE OF SELF-
MANAGEMENT SUPPORT
PARTNER ORGANIZATIONS
Living Healthy Champlain has achieved such significant successes primarily due to the
dedicated partnerships that have been formed. The following organizations have varying
degrees of involvement with LHC, but are all highly valued as key to driving the culture of
self-management support within the Champlain LHIN.
Renfrew County
Pembroke Regional Hospital
Whitewater Bromley/ Rainbow Valley
Community Health Centre
Petawawa Centennial Family Health Centre
Lanark County
North Lanark Community Health Centre
Ottawa West
Queensway Carleton Hospital
Carlington Community Health Centre
Pinecrest Queensway Community Health
Centre
Westend Family Care Clinic
West Carleton Family Health Team
Ottawa Central
Rideau Family Health Team
Somerset West Community Health Centre
Centretown Community Health Centre
The Ottawa Hospital Academic Family
Health Team
South East Ottawa Community Health
Centre
The Ottawa Hospital, Riverside Campus,
Nephrology
Sandy Hill Community Health Centre
Bruyère Academic Family Health Team
Ottawa East
Connexion Family Health Team
8
Wabano Centre for Aboriginal Health
Eastern Counties
Seaway Valley Community Health Centre
Centre de Santé Communautaire de l’Estrie
Williamsburg Non-Profit Housing
Corporation
Region-Wide
The Arthritis Society
Crohn’s and Colitis Foundation of Canada
Stroke Survivors Association of Ottawa
(Ottawa)
VHA Health and Home Support (Ottawa)
Community Support Coalition
Canadian Diabetes Association
University of Ottawa Heart Institute
(Ottawa)
Canadian Cancer Society
Alzheimer Society Ottawa & Renfrew
County
Community Diabetes Education Program of
Ottawa
Independent Family Physicians
Ottawa Regional Cancer Foundation
3C Foundation (Ottawa)
Weight Management Clinic, The Ottawa
Hospital
TRAINING
Living Healthy Champlain held four successful peer leader training sessions this year, resulting
in a total of over 60 capable and eager volunteer leaders. We are very proud of all our leaders,
and those who aren’t camera shy are featured below:
Among these individuals there are leaders trained to deliver the “Living a Healthy Life with
Chronic Conditions” self-management workshop from Stanford University in six different
languages: Arabic, Chinese, English, French, Hindi, and Vietnamese.
"I feel more in
control of the things
that aren't in my
control.”
8
COMMUNICATION & MARKETING
Living Healthy Champlain recognizes the importance of communication and consistent
messaging in the effort to develop a culture of self-management in the Champlain LHIN. One of
the main channels to communicate LHC’s work and the philosophy of self-management is via
the website: www.livinghealthychamplain.ca.
The Champlain CCAC has provided the use of the Champlain Healthline
(www.champlainhealthline.ca) platform to develop the interactive site for LHC. The link to the
highly resourced Healthline has allowed the LHC site more traffic and is also a mechanism in
which to obtain several other community resources. The expertise behind the development of
the LHC site has allowed for a registered users log-in site as well. This function enables our
leaders a forum for discussion amongst themselves, and also provides them with pertinent
registration information regarding their specific workshops.
This partnership with the Champlain CCAC will continue into the next year, and LHC will
continue to build and improve upon the current site to meet the needs of its users to the best of
its ability.
Getting the Word Out
Speaking engagements are another method Living Healthy Champlain has used to
spread
the message about self-management, self-management support, and the ways
in which LHC
can endorse these initiatives. The following large events featured an
LHC team member as
a presenter:










Crohn’s & Colitis & You Conference, April 2010, Ottawa ON
Café Scientifique, May 2010, Ottawa ON
Chronic Disease Management Strategic Planning Session, May 2010, Toronto ON
Advancing Chronic Disease Prevention & Management, June 2010, Regina Saskatchewan
RNAO Chronic Disease Management Institute, September 2010, Toronto ON
Taking Charge of Our Health Conference, November 2010, Toronto ON
Innovations in Health Expo, November 2010, Toronto ON
Self-Management & Mental Health Working Group, November 2010, Toronto ON
GUT Club, January 2011, Ottawa ON
Art & Science of Outreach Facilitation, January 2011, Ottawa ON
“More determination…to
deal with the problem,
whatever it took, exercising
you know, whatever it
took…I think that’s the
greatest impact”
9
2 N D ANNUAL LIVING HEALTHY CHAMPLAIN CHRONIC DISEASE SELFMANAGEMENT CONFERENCE
On March 30, 2010 over 150 health care
professionals in the Champlain LHIN
joined together to learn more about
implementing self-management and selfmanagement support programs into their
practice. Key note speakers included:
Mike Hindmarsh, Hindsight Healthcare
Strategies: “Building Self-Management
Support Into Your Practice”, Janis
Leiterman, VON Canada’s Director
Chronic Disease Prevention: “Initiating
Change in Health Systems” and
Management and Amireh Ghorob, Project Director for the American
Academy of Family Physician’s Peers for Progress: “Health Coaching
and Panel Management”.
In an attempt to meet the needs of the health care providers in the
Champlain LHIN to the best of our ability, Living Healthy Champlain
requested feedback from participants to improve upon the delivery of this
conference. Below are some of the key findings and comments:
What Further Support/Information is Needed?
 Support and funding for staff to attend training sessions
 Please think about including more mental health management of
chronic disease & the roles of mental health professionals
 Feedback from persons with chronic conditions - what sort of
support would be vital to them?
 Information on how to reframe my thinking from patient education to
self-management support
 Long-term evaluation research
10
PARTICIPANT FEEDBACK
11
OBJECTIVE 3: EVALUATING REACH, EFFECT OF STRATEGIES AND
INVESTMENTS
A key component of the Living Healthy Champlain effort is to evaluate the impact that increased
self-management support in our community and health care system has on the lives of Champlain LHIN
residents. The evaluation team at the Élisabeth Bruyère Research Institute evaluates the Stanford “Living
a Healthy Life with Chronic Conditions” workshops using questionnaires and focus groups. This work
helps to guide the proper growth and development of self-management support programs in the region
by understanding how the program helps, who it helps most, and who is not being reached or benefiting
from the program. This evaluation will judge the long-term program effects on changes in health
behaviour, health status, and health care utilization rates, as well as explore the role that patient
confidence and motivation has on participants’ own health management.
Since LHC’s inception in September 2009, 146 workshop attendees have participated in the
evaluation by completing a health questionnaire at the beginning of each workshop session. Participants
consent to have the same health questionnaire mailed to them 6 and 12 months after they participate in
the workshop. The health questionnaire surveys participants’ perception of their health and quality of
life, self-management behaviour, self-efficacy and health care utilization. The number of participants in
the health questionnaire grows each month and, as more responses are received, a better understanding is
gained about the workshop, including strengths and weaknesses and overall impact on participants and
their health. Responses are grouped together to understand the effect on the group and at this time we
are able to report on noteworthy trends in the data related to some participants’ self-reported health
status, symptoms, coping and confidence to manage symptoms and health care utilization patterns.
Demographics of Participant Population
More than three-quarters of those who have chosen to participate in the evaluation of the Living
a Healthy Life Workshops are female (78%) and a high proportion of this group (71%) are managing
multiple chronic conditions. Nearly three-quarters (71%) of the evaluation participants have arthritis
and/or a form of rheumatic disease, while nearly a third (32%) are living with diabetes. Other reported
conditions include Asthma (15%), Heart Disease (15%), Emphysema and/or COPD (9%) and Cancers
(6%).
Chronic Disease Prevalence
Participant
Gender
78
%
Female
12
22
%
Male
Cancer
Emphysema/COPD
Heart Disease
Asthma
Diabetes
Arthritis
Multiple Conditions
0%
20%
40%
60%
80%
The self-management workshops are having an impact on
participants’ reported symptoms and confidence to manage these
symptoms.
“I was hoping for a little more input
from other sources, other than me
having to go out and find these
[resources]. But I think it did focus
my attention on the whole process.”
Currently 34 participants have completed questionnaires at all
three time points: baseline, 6 months and 12 months after the workshop.
Early trends amongst these individuals indicate that the workshops are leading to a decrease in the level
of fatigue experienced by these participants, while the experience of pain appears to decrease soon after
participation in the workshops and increase slightly overtime though remaining lower than before
participation.
Participants’ confidence to self-manage their symptoms, including fatigue and emotional
distress, appears to be increasing following participation in the Living Healthy Workshops.
(1=Not Confident,
10=Totally Confident)
Confidence
Confidence about doing things
6.5
Keep fatigue from
interfering in your life
6
5.5
Keep pain from interfering
with your life
5
Keep emotional distress
from interfering with your
life
4.5
4
Baseline
6 Months
12 Months
Months Following Intervention
Workshop participants are reporting changes to health services usage after completing the
6-week course.
Visits in the last 6 Months
Participants in the evaluation are also reporting changes to their use of health services following
participation in the workshops. Out of the 34 individuals who have returned surveys at each time point,
six individuals reported visiting the
emergency department and the group
Health Service Usage
average number of visits for this
6
smaller group decreased over time
5
following the workshops. Overall,
Visits to
4
Family
the group average for physician visits
3
Physician
also decreased following
2
participation in the workshops.
Visits to
1
Emergency
Room
0
Baseline
6 Months
12 Months
Months Following Intervention
13
Rating
(0=None, 10=Severe)
While these preliminary findings from our participants who have filled out surveys up to one
year after the workshop are interesting, we need to collect information on the experience of more
workshop participants to understand if
these trends are shared by the larger
Severity of Symptoms
group and an effect of the workshops
6
for most people or just for the small
5.5
group who have responded. We are
actively trying to increase the number
Pain
5
of individuals who participate in the
Fatigue
4.5
evaluation of the workshops by better
communicating the importance of their
4
Baseline
6 Months 12 Months
participation and what the information
provided is used for, such as sharing
Months Following Intervention
results back with the community
through an annual report.
In addition to the health questionnaire, the Evaluation Team at the ÉBRI hosted four focus
groups in the fall of 2010. The team brought back original participants from workshops run in the fall of
2009, for a total of 21 participants. Focus group participants provided valuable, in-depth feedback on
their experience with the Living Healthy Champlain program and its impact on their lives. Several
common themes arose during the focus groups including: common barriers and facilitators to
successfully self-managing chronic conditions; perceived positive effects of the workshops; positive
features of working with a group of peers; and the importance of managing
the expectations of participants.
"…there are things available to
us and not only doctors can
help us, groups need to [as
well]…”
Focus Group participants identified barriers to managing their health
in the way they wanted too, including symptoms such as pain and fatigue,
lack of time, lack of transportation, financial needs and more. Participants
also reported barriers specific to the medical system including lack of access to services, over
prescribing medication, family physicians’ lack of knowledge of community resources.
The Stanford self-management workshop is highly valued by participants, especially as it assisted them
with goal setting, problem solving and coping. Participants in the focus groups also shared that the
workshop had a strong positive impact on changing their attitudes and motivating change in
exercise, eating habits and communication with caregivers and providers.
The focus group participants indicated several positive features of group work including, the
motivational capacity of the group, the opportunity to learn from others, a sense of connectedness and a
safe space to disclose personal experiences of living with chronic conditions.
“I’m starting to accept [the
diagnosis] more than I did. It
took a long time but I think this
course helped me.”
14
“[
Participants in the focus group also brought to our attention that
participants do not always have a clear understanding of what the course
would deliver. This left some participants pleasantly surprised, and, in
other cases, caused some frustration, speaking to a need to set the right
expectations. Some participants indicated that they were not used to
playing a key role in the management of their conditions, however, they indicated integrating this
role into their lifestyles in order to better cope with their conditions.
In addition to the Living Healthy evaluation, the evaluation team is concurrently working on
emerging grants to further the reach of effective self-management support in the Champlain LHIN. The
evaluation team has been awarded $90,000 to develop a national evaluation framework for chronic
disease self-management programs in Canada. This framework will help provide the comparative
information on outcomes of self-management support programs to understand their impact and for
whom, and how it achieves this impact. More comparative information on outcomes across programs
will better guide future development and implementation of these programs across the Champlain LHIN,
the province and country.
“…the first thing we did was talk about feelings
and…I was amazed that we all had the same
feelings of guilt, of depression, of frustration…it
didn’t matter what the illness was. And that, to me,
was really empowering”
15
PARTICIPANT FEEDBACK
16
FINANCIAL POSITION
Living Healthy Champlain has been fortunate enough to have full funding endorsement from the
Champlain LHIN. However, in order to achieve successes above and beyond the prescribed
deliverables, LHC relies heavily on the in-kind contributions from partner organizations, and has also
solicited external support from private funders. Further, in the last quarter of this fiscal year, the
Ministry of Health and Long-Term Care provided funding through the Ontario Diabetes Strategy for
self-management and self-management support in each LHIN. The chart below shows the division of
funds by percentage:
Funding Spread
3.58%
15.28%
Champlain LHIN
20.17%
60.97%
In-Kind Contributions
Ministry
Private
The private funders are two pharmaceutical companies; sanofi aventis and Merck Canada. Each
company provided unrestricted funds to help support the initiatives set forth by LHC. Living Healthy
Champlain is keen on developing as many positive, supportive relationships as necessary to provide
sustainability and resources to deliver services and opportunities to target audiences. LHC is also very
cautious upon engagement of these partnerships and is sure to maintain the interests of the residents and
health care providers of the Champlain LHIN throughout all activities.
“This workshop helped me deal
with the shock that doctors can’t
always help you.”
17
STEERING COMMITTEE MEMBERSHIP
Dr. Larry Chambers, President Élisabeth Bruyère Research Institute
Karen Patzer, Senior Planner, Champlain LHIN
Dr. Sharon Johnston, Élisabeth Bruyère Research Institute
Dr. Clare Liddy, Élisabeth Bruyère Research Institute
Debbie McGregor, Bruyère Academic Family Health Team - Chair
Ilsa Eustice, Manager, Business and Community Development, Champlain CCAC
Robin Lowry, Community Engagement Coordinator, Champlain CCAC
Kelli Tonner, Manager, South East Ottawa CHC
Melissa Cormier, Arthritis Society
Lise Richard, Community Support Ottawa
Jo Brunskill, Lay representative
Nancy Stewart, Director, Complex Continuing Care, Bruyère Continuing Care
Erin Rae, Regional Coordinator CDSM, Bruyère Continuing Care
Hannah Irving, Evaluation Coordinator ÉBRI
Sarah Mae Ives, Outreach Coordinator ÉBRI
Sophie Des Rosiers, Program Assistant, Bruyère Continuing Care – Recorder
"There is nothing for caregivers
in the community.
It [the workshop] was
powerful."
18
PARTICIPANT FEEDBACK
All quotes throughout the
Annual report are from
actual workshop
participants in the
Champlain LHIN.
19