The Ministry of Health and Long-Term care has developed a chronic disease prevention and management framework (CDPM). Its purpose is to improve both chronic disease prevention and the management of chronic diseases. The model attempts to shift the health care system from acute management of disease to the prevention of chronic disease in order to achieve improved clinical, functional, and population health outcomes.

The CHAP program is an example of the CDPM framework in practice. CHAP is designed to promote cardiovascular health awareness including blood pressure monitoring among older adults to prevent illness and death associated with cardiovascular disease. The components of the framework and CHAP in practice are provided as follows.

1. Health Care Organizations
   Health care organizations utilize systematic efforts to improve prevention and management of chronic disease, characterized by:
   
   Strong leadership
   CHAP programs have local lead organizations with a track record of community leadership with local champions for it among its family physicians and pharmacists
   
   An alignment of resources and incentives
   CHAP is a project of the Ontario Ministry of Health Promotion’s Stroke Strategy, the Canadian Stroke Network, Élisabeth Bruyère Research Institute in Ottawa and the Department of Family Medicine at McMaster University in Hamilton. CHAP has received awards from Blood Pressure Canada and the Canadian Association of Pharmacists.
   
   Accountability for results
   CHAP aims to improve outcomes for clients, population health and the system. CHAP lowered the blood pressure among older patients in family practices in Airdrie, Alberta (2005), improved cardiovascular health in the community as demonstrated by the ICES data, and improved monitoring of blood pressure among family physicians (2004 in Ottawa and Hamilton). The data collected from CHAP communities is compared with non-CHAP communities.
   
2. Personal Skills and Self-Management Support
   The program works to empower individuals to build skills for healthy living and coping with disease.
   
   Emphasizes individuals/families central role in health and care
   Patients receive an invitation from their family physician to attend CHAP pharmacy sessions. At which time, they are given their own blood pressure and cardiovascular disease risk profile to take home. The CHAP session also provides information on the prevention of heart disease and stroke.
   
   Engaging in shared decision-making
   Following a CHAP, the participant can discuss their CHAP information with their family physician, pharmacist, and family.
   
   Provide access to education programs and health information
   Volunteer peer health educators provide information about local health promotion resources.
   
   Provide access to education programs and health information
   Volunteer peer health educators provide information about local health promotion resources.
   
   Behaviour modification programs
   A letter from the family physician results in 50% of their patients attending CHAP sessions.
   
   Counseling and support services
   Pharmacists are present in the pharmacy and can provide information about cardiovascular disease prevention resources.
   
   Integration of community resources
   CHAP connects local family physicians and pharmacists to form a coalition of local agencies to promote continuity of care.
   
   Follow-up
   Participants are encouraged to attend multiple CHAP sessions and to inform their family physician and/or pharmacist of their blood pressure and cardiovascular disease risk profile.
   
3. Delivery System Design
   The design of the delivery of CHAP focuses on prevention, improved access and continuity of care and flow through the system.
   
   Interprofessional teams
   Local physicians, pharmacists and community nurses work as a team.
   
   Integrated health promotion and disease prevention
   CHAP training and deployment of volunteer peer health educators.
   
   Planned interactions with active follow-up
   If a participant’s blood pressure is high, the CHAP participant is recommended to contact their family physician and/or pharmacist. Family physicians receive a summary of their patients who attended CHAP sessions listed according to level of blood pressure. Six months later, family physicians receive a summary of the percent of their patients whose blood pressure is not under control compared to percent in other family physician offices.
   
   Adjustments, Innovations in practice
   Family physicians are asked to generate a list of all their patients who are at high risk of cardiovascular disease and to send invitation letters to these patients. Family physicians can use the CHAP summary participant reports in their practice.
   
   Information systems
   A CHAP data base has been generated through a datafax system (Clinforma). CHAP has a website with password protected family physician and participant CHAP data.
   
   Outreach and population needs-based care
   The CHAP Implementation Guide instructs local c1ommunities on how to implement CHAP with the support of a project manager/coordinator.
   
4. Provider Decision Support
   Family physicians are enabled to integrate evidence-based guidelines into their daily practice.
   
   Provider education
   The CHAP Implementation Guide appendices outline the roles and responsibilities of the local lead organization, local CHAP coordinator, volunteer peer health educators, family physicians, and pharmacists.
   
   Tools
   CHAP blood pressure and cardiovascular disease risk profile forms are utilized as disease assessment and management flow sheets for CHAP participants.
   
   Clinical information systems
   The creation of a CHAP datafax data base and a password protected CHAP website for participants and family physicians.
   
   Provider alerts and reminders
   There are protocols for referral to care providers of older adults with high blood pressure at CHAP sessions.
   
   Access to specialist expertise
   A community health nurse is on-call, and the pharmacist is in the pharmacy at the time of the CHAP session.
   
   Routine reporting/feedback, evaluation
   A continuous quality improvement loop is achieved by providing summary reports to family physicians.
   
5. Information Systems
   These systems are essential to providers to provide quality care; to support clients in managing their disease and for integrating services across health systems.
   
   Electronic health records
   Password protected CHAP website for family physicians.
   
   Case management software
   This is utilized by the CHAP website.
   
   Client registries integrated with electronic health records
   The potential is available to link CHAP blood pressure and cardiovascular disease risk profile information to family physician and pharmacist patient databases. The BP-Tru automated measuring device has a USB port.
   
   Web support
   There exists a CHAP website for participants, family physicians and pharmacists.
   
   Information for clients
   Paper CHAP blood pressure and cardiovascular disease risk profile information is given to participants.
   
   Links
   CHAP database link to family physician and pharmacy databases.
   
6. Healthy Public Policy
   Develop and implement policies to improve individual and population health and address inequities.
   
   Legislation, regulations such as non-smoking bylaws
   CHAP is low-cost, practical, community wide program.
   
   Fiscal, taxation measures
   Volunteers run the CHAP sessions. The cost is about $30,000 to pay a CHAP local coordinator and $10,000 for other CHAP local expenses.
   
   Guidelines
   The CHAP Community Implementation Guide has been revised and is available on the CHAP website.
   
   Organizational change
   The training and deployment of CHAP volunteer peer health educator s is an integral resource for CHAP.
   
7. Community Action
   These are those activities that remove barriers to healthy living and work to promote safe, enjoyable living and working conditions.
   
   Collaboration between healthcare sector and community organizations
   Collaboration of linkages established with family physicians, pharmacists, local lead organization and other local CHAP partner organizations.
   
   Effective public participation and intersectoral collaboration
   Community coalitions are formed to deliver CHAP in the community and include public health units, hospitals, and health and social service community agencies. Volunteer peer health educators are a central resource for CHAP. A high participation rate of older adults (35% of population of older adults) attends CHAP sessions.
   
8. Supportive Environments
   These encourage communities to increase control over issues affecting health.
   
   Physical environments
   CHAP is implemented in pharmacies and other venues throughout the community.
   
   Social and community environments
   Pharmacies are frequented by older adults and CHAP sessions are scheduled during mornings; a preferred time of older adults. CHAP sessions are seen as a social event for an older adult. Local municipalities typically see CHAP as a community builder.
   
   The framework results in productive interactions and relationships. These are characterized by:
   
   Informed, activated individuals and families
   Volunteer peer health educators are available at CHAP sessions. Risk profiles provided to individuals at CHAP sessions and health promotion resources are available at CHAP sessions and on the CHAP website.
   
   Activated communities and prepared proactive community partners
   Linkages and collaborations formed among health professionals, community agencies, local volunteers and older persons in community.
   
   Prepared, proactive practice team
   Risk profiles faxed to physicians, with pharmacists on-site for referrals.