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Implentation Guide


1. Acknowledgements


The CHAP Working Group would like to thank the following organizations for their contributions to the on-going success of the CHAP Program:
  • Bayshore Home Health
  • Blood Pressure Canada
  • The Canadian Institutes of Health Research
  • Canadian Hypertension Education Program
  • The Canadian Stroke Network
  • CareFor Health and Community Services
  • Community Care Access Centre of Wellington Dufferin and Headwaters Health Care Centre
  • Community Care City of Kawartha Lakes
  • Community Care Northunberland
  • Community Home Assistance to Seniors
  • The Department of Family Medicine, McMaster University
  • The Department of Family Practice, Faculty of Medicine, University of British Columbia
  • Élisabeth Bruyère Research Institute, a University of Ottawa and Bruyère Continuing Care partnership in Ottawa
  • The Friends
  • Fig.P Software Incorporated
  • Institute for Clinical Evaluative Sciences
  • Leamington and Area Family Health Team
  • Leamington District Memorial Hospital
  • New Horizons Seniors Centre
  • Ontario Heart and Stroke Foundation
  • Ontario Ministry of Health and Long-Term Care
  • Ontario Ministry of Health Promotion
  • Orillia Soldiers’ Memorial Hospital
  • PrimaCare Community Family Health Team
  • Pembroke Regional Hospital- District Stroke Centre
  • Seniors Health Research Transfer Network
  • South West Local Health Integration Network
  • Stratford Meals and Wheels and Neighbourly Services
  • Sunset Country Family Health Team
  • Tillsonburg Community Centre
  • Team for Individualizing Pharmacotherapy in Primary Care for Seniors
  • VON Middlesex-Elgin
  • VON Niagara
  • VON Oxford
  • VON Perth Huron
  • VHA Home HealthCare
  • VSM Med Tech Ltd., Coquitlam, BC, Canada
  • YMCA of Collingwood

The CHAP Working Group would also like to thank all of the physicians, pharmacists, nurses and Family Health Teams for their on-going support of CHAP, and the hundreds of volunteers for their time and dedication to the CHAP program.

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2. How to Use the Implementation Guide


This Guide has been put together with the end-user in mind. It contains the information and resources needed to successfully implement CHAP in any community. The Guide is available at:
All of the required documents referred to throughout the Guide can be downloaded from the website (in MS Word and Acrobat) and edited to best suit an individual community’s needs.

This Implementation Guide builds on the tools and processes developed, the feedback received, and the successes experienced since CHAP was initiated in 2000. The goal of this Guide is to provide a “road map” for communities interested in implementing CHAP.

Based on the previous experience of community-wide implementation of CHAP, the Guide is set up on a 24 week schedule which can be adapted to the needs of your community. Tasks are laid out on a bi-weekly basis to help track progress. The first 12 of 24 weeks are designated for tasks related to hiring resources, mobilizing the community, and recruiting the partners necessary to operate CHAP. The remaining 12 weeks are designated for operating the CHAP community-based sessions and to completing CHAP reports.

Local CHAP coordinators participate in regular teleconference calls led by the Regional Manager to facilitate discussion among the local CHAP coordinators. In turn, the Regional Manager will communicate progress, milestones, and any challenges to the CHAP Central Group.

The time and effort needed to successfully implement CHAP will vary in each community. Accordingly, this Guide is meant to provide direction and assistance with implementing the Program. While some aspects of the Program are considered critical and necessary, Local CHAP Coordinators should be aware that the Guide’s proposed approach and schedule is flexible and written so that it can be tailored to meet individual community needs.

The Website - www.chapprogram.ca The website includes a downloadable version of the Guide, its appendices and resources. It lays out the steps required to successfully implement CHAP in a consistent format across communities. It contains background information, objectives, checklists, samples of forms, letters, presentations, job descriptions, recommendations, training material, advertising, and more. It can also be used to contact the CHAP Central Group and both the Regional Manager and Local CHAP Coordinators via an electronic discussion board (list serve).

Local CHAP Coordinators will be able to access a discussion group for advice and support during their implementation of CHAP. Access to the CHAP discussion group will be made available to designated individuals. Local CHAP Coordinators will need to forward their e-mail addresses to the Regional Manager at the beginning of the implementation process. The list serve is a mailing list that automatically forwards messages to all designated people. It is used to give Local CHAP Coordinators Guide updates and important messages can automatically be forwarded to the larger group. In addition, discussions between the group members can be moderated so that suggestions, challenges and helpful tips can be shared.

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3. Introduction


Welcome to CHAP!

CHAP has been in existence since 2000 and was developed through a number of pilot projects, scientific trials, and community-wide demonstrations.

CHAP…

Is an innovative program designed to promote cardiovascular health awareness including blood pressure monitoring among seniors to prevent illness and death associated with cardiovascular disease.

Connects community-based health promotion and prevention activities for seniors with the care provided by their family physician and pharmacist, and involves public health representatives, volunteers, the local media and community organizations.

Aims to bring all individuals and organizations together within a community to work as partners to promote and actively participate in the prevention of cardiovascular disease.

The goal of CHAP is to implement a volunteer peer health educator program of cardiovascular health awareness and blood pressure monitoring in communities across Ontario and elsewhere.

CHAP is made available, free of charge, to all senior community residents. It offers opportunities for multiple blood pressure readings and the promotion of healthy eating, physical activity and smoking cessation, all modifiable risk factors for heart disease and stroke.

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3.1 Background

The Problem

Cardiovascular disease is the leading cause of death in Canada. High blood pressure or hypertension affects 1 in 5 Canadian adults and is a modifiable risk factor for heart disease, stroke, and kidney disease. Nine out of 10 Canadians will develop hypertension during their lifetime. High blood pressure has no warning signs or symptoms – which is why it is often called a ‘silent killer.’ Despite efforts to overcome barriers to high blood pressure detection and management, high blood pressure remains one of the most significant health problems facing Canadians.

Blood pressure can be challenging to assess accurately because of its natural variability and measurement challenges. Some people have higher blood pressure readings in their doctor's office because they feel anxious in this setting. Others have normal blood pressure when measured in the doctor’s office, but have high blood pressure in other situations.

CHAP participants are invited to measure their blood pressure with assistance from a trained volunteer in a familiar community setting. Plus, CHAP participants can take home a copy of their results and give their permission to have their health information obtained at a CHAP session shared with their family physician and pharmacist. This allows physicians and pharmacists to follow-up with their patients if required.

A Solution

CHAP is a community-based program that brings together local family physicians, pharmacies, public health representatives, volunteers, and community organizations to work as partners to promote and actively participate in the prevention of cardiovascular disease.

The success of CHAP is based on the recruitment of all local family physicians and pharmacies to participate in the Program. Participating physicians invite all of their patients who are at risk of cardiovascular disease to attend CHAP community-based sessions using several strategies: a personal letter of invitation; or community-wide advertising.

Volunteer peer health educators (trained by community health nurses) lead CHAP community-based sessions. During the sessions, volunteers assist participants to measure their blood pressure using an accurate, portable device that is validated (for example, the BP-Tru), and record their blood pressure reading and other cardiovascular risk factor information on a Risk Profile Recording Form. With the participant’s permission, the blood pressure reading and the risk profile is forwarded to a computerized database which in turn sends the information to family physicians by fax (or mail). A copy of the blood pressure reading and risk profile is also given to each participant and to their regular pharmacist. Physicians follow up with patients where appropriate.

A community health nurse is on-call during the sessions, and a recommendation protocol, established in consultation with participating family physicians, is used to guide re-assessment of participants with very high or low readings and to ensure referral for follow-up. Additional educational materials and community-specific resources related to healthy eating, physical activity and smoking cessation are also made available at the session.

Click here to view a sample Risk Profile Recording Form (pdf)

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4. CHAP Program Entry


4.0 Key Players of the Cardiovascular Health Awareness Program



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4.1 CHAP Working Group

Since 2001, the CHAP Working Group has been responsible for the overall development, implementation and planning of CHAP. The Working Group includes representatives from government and non-government bodies, academia and research institutions, and other health focused foundations and organizations.

The CHAP Working Group communicates program changes, and provides advice to local CHAP programs. The CHAP Advisory Group co-chairs are: Larry W. Chambers, PhD, FACE, FPHM(UK), President, Élisabeth Bruyère Research Institute; and Janusz Kaczorowski, PhD, Professor and Research Director, Family Practice and Child and Family Research Institute, University of British Columbia, and Lisa Dolovich, BScPhm, PharmD, MSc Research Director & Associate Professor, Department of Family Medicine, McMaster University Scientist & Associate Director, Centre for Evaluation of Medicines.

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Regional Manager

The CHAP Regional Manager is a member of the CHAP Working Group and liases with all local CHAP programs. The Regional Manager works closely with the Local Lead Organization and all Local CHAP Coordinators on all matters concerning CHAP to foster the success of the program.

Responsibilities of the Regional Manager:

  • Communicate directly with all the Local CHAP Coordinators and Local Lead Organizations
  • Responsible for the overall planning, and management of the Program
  • Advise and guide the Local CHAP Coordinators on the implementation and operation of CHAP within their community
  • Advise and guide the Local CHAP Coordinators in the recruitment of physicians, pharmacies, and volunteer peer health educators
  • Create formal and informal networking opportunities for all Local CHAP Coordinators and other local agencies
  • Responsible for preparing reports on activities across all CHAP communities for program management and evaluation

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4.2 Local Lead Organization

The local lead organization could be a community organization such as a health-oriented agency, a public health unit, or a local group whose mandate or interest in cardiovascular health promotion coincides well with the CHAP mandate.

The local lead organization supports CHAP’s mandate of raising the awareness of the benefits of cardiovascular health and agrees to implement CHAP within the community.

The actual lead organization will vary across communities depending on the organizations located within the community.

There is also the opportunity for a Family Health Team to be a local lead organization. A Family Health Teams (FHT) is an approach to primary health care that brings together different health care providers to co-ordinate the highest possible quality of care for patients. Family Health Teams are designed to give doctors support from other complementary professionals. Most Family Health Teams will consist of doctors, nurses, nurse practitioners and other health care professionals who work collaboratively, each utilizing their experience and skills.

The local lead organization will provide guidance and support to the Local CHAP Coordinator throughout the implementation and on-going operation of CHAP in the community. The resources required to operate CHAP at the local level are normally channelled into the local lead organization.

Responsibilities of the Local Lead Organization

  • Communicate with the local team to ensure that it has the required paper work and funding necessary to manage the Program, and to report on CHAP’s progress
  • Manage program files, databases, and information required for the ongoing evaluation of CHAP in the community
  • Mobilize the community to actively participate in CHAP
  • Undertake an environmental scan of the community to determine potential partner organizations, key contacts, opinion leaders, existing programs and resources, local branches of health-oriented foundations, media channels, etc.
  • Develop and implement a communications plan tailored to the community’s needs
  • Recruitment of a community health nurse
  • Assist in the preparation of CHAP reports as required

The local lead organization may have an individual, or know of an individual, who has a vested interest in health issues, feels passionate about the community and understands the importance of mobilizing a community. This individual may be interested in playing a lead role in championing the implementation of CHAP. Known as the Local CHAP Champion(s), this individual can be extremely helpful in identifying methods and mediums that are appropriate to recruit community partners and to raise community awareness of CHAP. Past champions have been physicians, pharmacists, volunteers, and other leaders in the community.

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4.3 Local CHAP Coordinator

Once the lead local organization is established from the community, the search begins immediately for a Local CHAP Coordinator. This recruitment process can take approximately 4-6 weeks.

Responsibilities of the Local CHAP Coordinator

  • Work with the Local Lead Organization and the Regional Manager to facilitate the successful operation of CHAP
  • Assist in the day-to-day operation of CHAP within the community
  • Assist in mobilizing the community to actively participate in CHAP
  • Assist in the development of a Communications Plan tailored to the community’s needs
  • Aware of local resources for healthy living; smoke-free living, healthy eating and physical activity and actively promote them to CHAP participants
  • Understand the gaps that may exist in local resources for healthy living
  • Recruit, retain and coordinate the participation of all local physicians and pharmacists and volunteer peer health educators
  • Assist in the development and delivery of information sessions and learning sessions for physicians, pharmacists, volunteer peer health educators and other key partners
  • Recruit community members to participate in the CHAP sessions
  • Advise and guide the community health nurse on training and monitoring of volunteer peer health educators
  • Initiate, plan and develop a quality volunteer program
  • Recruit, select, and oversee training of volunteer peer health educators
  • Deliver on-going volunteer appreciation to volunteer peer health educators
  • Provide support to volunteer peer health educators to run the CHAP sessions
  • Schedule and coordinate the CHAP sessions
  • Oversee the data management of CHAP sessions through the forwarding of the Risk Profile Recording Forms to identified physicians and pharmacists
  • Prepare CHAP reports as required

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4.4 The Community

The most important partner in the implementation of CHAP is the community CHAP is a community-wide effort. It is the base for the resources required to conduct CHAP sessions and the audience for raising the awareness of cardiovascular health and CHAP.

CHAP has the ability to empower community members to prevent heart disease and stroke. Community resources are redirected to run CHAP sessions and build capacity in the community to promote cardiovascular health. The character of each community determines the specifics of the CHAP sessions.

Within the community, certain organizations, businesses, residents and local media will be identified as those which would benefit from a heightened awareness of CHAP and who may choose to play a lead role in participating in CHAP. Many of these groups and individuals will be identified during weeks 1 to 3 when efforts are being made to “mobilize the community.” This “breakdown” of the community into smaller components is well documented in the community profile that is developed during the environmental scan.

Communications and marketing efforts should be targeted towards both the identified groups within the community profile, and the larger community as a whole.

Each community’s Communications Plan will identify appropriate mediums or channels through which information can be broadcast to the larger community. The Plan will also call for posters, press releases, newspaper ads and speaking engagements all of which work towards this goal of an increased community awareness of CHAP. (See Appendix 2.1 for a Sample Communications Plan)

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4.5 Primary Care Providers, Pharmacists, Volunteer Peer Health Educators, Community Health Nurse

Detailed information on the role that these key partners play in CHAP is found in weeks 4 to 8 when recruitment efforts get underway.

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4.6 Information Management

The blood pressure readings and cardiovascular risk factor information on the Risk Profile Recording Form (See Risk Profile in Appendix 7.3) is collected and sent to a computerized database with each participant’s permission or consent. This information is used for the appropriate follow-up of participants by family physicians and the management of the CHAP program. This health information is kept secure and private. The blood pressure readings and the cardiovascular risk information data is anonymized so that individual participants are not identified. When all of the data is examined, the CHAP Working Group looks only at large amounts of information; specifically, all seniors who have participated in a CHAP session across Ontario. No single person’s records or personal information is reported.

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5. Readiness and Assessment of Your Community


The assessment of your community begins once a Local CHAP Coordinator has been hired and oriented to the CHAP Program. The assessment will take between one to three weeks to complete. Once the following objectives have been completed, recruitment begins.

Objectives

    • 1. To undertake an Environmental Scan of the community.
    • 2. To develop a Community Profile of the organizations, agencies, associations, working groups, media outlets and opinion leaders in the community.
    • 3. To initiate a Collaborative of Organizations.
    • 4. To develop a CHAP Communications Plan that is tailored to the community’s needs.

Communities are like people – they come in all shapes and sizes, and each one has a preference for doing things a certain way. For this reason, the approach taken to mobilize, motivate, and raise the collective awareness of an issue will vary across communities.

Mobilizing your community is a crucial step in the CHAP implementation process. The more people talk about an issue, the greater the chances are for involvement and benefit. As well, the more individuals are given an opportunity to participate in an event, the more likely they will be to work towards its success.

Mobilizing your community around CHAP is:

  • A means of generating interest in, and commitment to, CHAP
  • Communicating with key people and agencies about CHAP
  • Encouraging people to be involved in CHAP’s development and implementation

Taking time to research, understand and communicate with your community will ease the implementation process. A community approach to implementing CHAP depends on engaging key contacts identified in the community and exploring ways for individuals and organizations to participate.

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5.1 Undertake an Environmental Scan of the Community

The first step in mobilizing a community and raising its awareness of CHAP and cardiovascular health issues is getting to know how it works and who makes things happen. You will need to find out what key agencies, working groups, community champions and physician opinion leaders exist.

An environmental scan is researching how a community works. The research is done through phone calls, internet searches, visiting community groups and organizations. The end-result is a community profile that is essentially a database of:

  • Relevant organizations, agencies and foundations.
  • The community champions – the “movers and shakers” or the individuals who make things happen in the community. Many communities recognize their volunteer leaders, and often name someone “Volunteer of the Year”.
  • Physician opinion leaders. Make a list of potential physician opinion leaders by asking each person you speak who they feel is the local physician expert on cardiovascular health issues. This might be one physician or several.
  • Researchers or administrators who are involved in community and health-oriented projects.
  • Seniors Groups and Centres.
  • Family Health Teams.
  • Community Health Centres.
  • Chronic Disease Prevention Program Manager of Local Public Health Unit.
  • Heart Health Coordinator at the Local Public Health Unit.
  • Community Support Agencies.
  • The opportunities that exist to help spread the word about CHAP. For example, newsletters of relevant groups, possible speaking venues, briefings at relevant organization meetings, local websites and City Council public meetings.
  • Media channels to communicate with the community about CHAP. For example, names of newspapers and their city editors, television stations and their key people, radio stations and key reporters, community newsletters, and public places to post posters.

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5.2 Develop a Community Profile

The following is a list of places and tools that can be used to help gather the information needed to develop a comprehensive community profile.

  • Phone Book: The Yellow Pages and www.411.ca can help you put a list together of agencies and organizations that you may want to speak with to obtain support for CHAP.
  • Internet: Looking at your community’s website will help you to gain insight into how the city’s administration works. “Inside City Hall” is an icon that will often outline the City’s administrative structure, working groups, and initiatives. “Mayor’s office” is another icon that will most often outline some the more prominent projects underway. These places may provide an opportunity for CHAP to be highlighted. City websites often list agencies, working groups and foundations in the area.
  • Mayor and Mayor’s Council: Phone the Mayor’s office. The Mayor may be able to direct you to the relevant groups to recruit volunteers, or how to best disseminate information on CHAP within your community. Perhaps there is a health promotion-working group within the City structure. Or, the Mayor may be willing to have city councillors briefed on CHAP at an upcoming council meeting.
  • Hospital Administrator(s): Find out who the hospital administrator(s) is in your community. Contact them and arrange for a meeting to introduce CHAP. They may also be helpful in finding the physician opinion leader, volunteers, and possible speaking engagements. Ask the Hospital Administrator if it would be possible to post the launch of CHAP to the “What’s New” section of the Hospital’s website.
  • Volunteer Groups: Review the list provided below. These are the groups from which volunteer peer health educators may be recruited.
    • Senior’s Centres, Senior Clubs, Senior Groups
    • Volunteer Centres, Directories, or Referral Services
    • Hospitals (Volunteer Groups)
    • Churches (Community Church Group)
    • Non-Profit Organizations and Service Clubs (For example, Alzheimer’s Society, Diabetes Association, Canadian Legion, Heart and Stroke Foundation, Kinette and Kinsmen Club, Knights of Columbus, Lions and Lioness Clubs, Recreation Centres, United Way, VON and the YMCA/YWCA)
    • Volunteer Recruitment Fairs (For an older audience)
    • Community Centres
    • Retirement Homes
    • Non-Profit Organizations and Service Clubs
    • Public Buildings
    • Businesses / Shopping Centres
    • Other Health Care Offices
    • Personnel Directors
    • Speakers' Bureaus
    • Chambers of Commerce

Remember that all of these potential resources may not be available or appropriate for every community. The Local CHAP Coordinator must determine what resources are best suited to CHAP’s mandate for their individual community.

Once the environmental scan is completed, all of this information should be used to compile a Community Profile. Prioritize those groups or individuals identified in the community profile to know whom to contact first.

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5.3 Initiate a Collaborative of Other Organizations

While conducting the environmental scan of your community, you may have found that there are other collaborative organizations that already exist in your community who have mutually supportive activities. For example, the Diabetes Initiative, the Ontario Stroke Network, the Healthy Communities Fund, the Local Ontario Heart Health Program and Local Health Integration Network (LHIN) and LHIN Aging at Home projects. Finding ways to connect with collaborative organizations with similar interests may be of assistance in promoting CHAP to the community and identifying volunteers to be volunteer peer health educators.

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5.4 Develop a Communications Plan

The development of a comprehensive communications plan is an integral component of CHAP’s success at the community level. Your communications plan will guide how and when CHAP resources speak to the community and the manner in which CHAP information is disseminated.

A sample communications plan is provided in Appendix 2.1. It can be used as a guide to develop a plan that is tailored to your community’s needs. Appendices 2.3, 2.4, 2.5 and 2.6 also provide samples of press releases and print materials.

Your CHAP communications plan should outline the following:

  • CHAP Program Goals
    • A bulleted list of overall goals of CHAP.
  • CHAP Communications Goals
    • A bulleted list of goals for CHAP’s success within your particular community.
  • Targeted Audiences
    • A list of key audiences to whom any information dissemination strategies will be targeted.
  • Key Messages
    • General: A list of 3-5 bullets outlining key messages to consistently relay to the public.
    • Specific: A list of more detailed messages that could be highlighted when the opportunity arises.
  • Channels for Communications
    • A list of contact information for media outlets. For example, print, radio, television, & internet.
    • A list of networking opportunities. For example, community gatherings, churches, senior centres, that can be used to help raise awareness of CHAP within your community.
  • Useful Resources
    • Print Material: Posters, brochures
    • Media: Press releases, public service announcements
    • Potential speaking engagements
  • Timeline
    • A schedule of the overall communications plan and its deliverables.

A sound communications plan will ensure a consistent approach when speaking to the community through a variety of mediums. Once your plan is developed, use it as a guide for when, how and where you communicate with the public. Communicating with the public and key partners on a regular basis will help to keep the momentum of CHAP strong.

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6. Recruitment


Objectives

To begin the recruitment of:

    1. Physician Opinion Leader,
    2. Local Primary Care Providers including Physicians, Family Health Teams, Community Health Centres and Nurse Practitioners,
    3. Local Pharmacist Champion,
    4. Local Pharmacies and Pharmacists,
    5. Community Health Nurse, and
    6. Volunteer Peer Health Educators

Recruitment will between one to three weeks of time. This will take you into the second month of CHAP initiation into your community.

The recruitment of physicians and pharmacists to actively participate in CHAP is very important. These two professional groups are a major building block for implementing CHAP in your community. The lower the participation rate, the more challenging it is to operate CHAP, and maintain its program link to primary care.

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6.1 Physician Opinion Leader

The fact that CHAP has been highly successful in recruiting a maximum number of physicians to it is largely attributed to its use of the physician opinion leader model. These are physicians who influence their peers’ medical practice.

Identifying a physician opinion leader in your community and at the outset of the CHAP implementation process is helpful.

Other physicians value a physician opinion leader’s thoughts and preferences and as such, the opinion leader is a powerful CHAP collaborator.

    • Physician Opinion Leaders are highly regarded by their peers and seen as experts in cardiovascular health. This enables them to have the ability to influence the decisions of their peers in areas pertaining to their expertise. They have a natural ability to persuade and attract the participation of others in CHAP through their expertise and enthusiasm for cardiovascular health issues.
    • A CHAP physician opinion leader is the physician that other physicians call when they have a difficult case of hypertension (CVD) in their office, or when they have a question about hypertension (CVD).
    • Physician Opinion Leaders are a networking resource because of their understanding of the social and communication networks of other physicians. They will be very knowledgeable as to how to best engage the majority of their peers into CHAP.
    • They have a keen interest in health promotion and community development.

There are a number of ways to find the physician opinion leader in your community. Here are several suggestions to assist in identifying a physician opinion leader.

    1. Networking: Talk to local physicians and other community contacts and ask about physicians who are involved in community health or have a particular interest in cardiovascular health promotion.
    2. Environmental Scan: A physician opinion leader may have been determined during the environmental scan given that opinion leaders are often found in hospitals, research labs, academic posts and private practices. Review your community profile to see if there are any relevant groups or associations that could be contacted to help identify a local physician opinion leader.
    3. Family Health Team/Community Health Centre: Contact the Executive Director or Administrator of local Family Health Teams/Community Health Centers. They may not only want to participate in CHAP, but may have a physician who would be a physician opinion leader or physician champion for CHAP.
    4. Local Hospital Administrators or Medical Officer of Health: Phone your local Hospital Administrators and/or Medical Officer of Health and ask if they are aware of a potential local physician opinion leader on cardiovascular health issues.
    5. Local Lead Organization: Discussions within your local lead organization may lead to a local physician opinion leader.
    6. Pharmacists: When speaking with pharmacists regarding CHAP, take the opportunity to ask them who they view as the local physician expert or advocate for cardiovascular health issues.

Once you have identified a physician opinion leader, arrange a meeting to introduce them to CHAP and their role in establishing CHAP in the community. Ask the physician opinion leader to play a key role in the recruitment of physicians including:

  • Delivering presentations at information sessions or meetings.
  • Signing letters to local physicians.
  • Talking with other physicians about CHAP on an informal basis.
  • Helping to identify alternative ways to recruit local physicians.

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6.2 Physicians and Local Primary Care Providers

Finding Physicians

There are several ways to find physicians in your community:

    1. The Phone Book: Look in the yellow pages and www.411.ca
    2. Internet searches
    3. Memberships in medical associations. For example, the Ontario Medical Association
    4. The Local Public Health Unit
    5. Family Health Teams and Community Health Centres

Once you have a complete list of physicians/primary care providers, record all contact information to enable you to recruit physicians/primary care providers.

How to Recruit Physicians

There are a number of methods that can be used to recruit physicians:

    1. Hold an information session hosted by the physician opinion leader.
    2. Attend an existing meeting of physicians where CHAP can be an information item on the agenda.
    3. Mail letters to local physicians and follow up with phone calls and office visits.

It is highly unlikely that all physicians will be recruited by using one particular method only; several methods need to be used consecutively in order to attract a high level of physician participation.

1. Information Session

A sample Power Point presentation that could be delivered during an information session can be found in Appendix 3.0. Many physicians in the community will not be able to attend the session for a variety of reasons. Take attendance at these session so that follow up phone calls and letters can be made to non-attending physicians.

The physician opinion leader can sign the invitation for physicians to attend this information session. The invitation letter should briefly introduce CHAP and outline the format for the session, using:

At the end of the session, hand out the Family Physician Letter of Understanding (Appendix 4.2) and the Family Physician Information Sheet (Appendix 4.3) so that physicians who wish to participate can indicate their preference for inviting patients to participate in CHAP. In addition, include the CHAP Protocol for Blood Pressure Readings (Appendix 4.4) so physicians are familiar with the procedure followed at CHAP sessions.

2. Attend an Existing Physician Meeting

Another effective way to reach physicians is to ask to be put onto the agenda of an existing physician meeting. Such meetings might take place at the hospital, within a family health team, at an academic institution, or within the local public health unit. Ask if the physician opinion leader or local CHAP coordinator, or representative from the Local Lead Organization or CHAP Central could provide an overview of CHAP. The Information Session Sample Presentation (Appendix 3.0) could be modified to best suit the meeting. Presentation handouts include:

3. Letters, Phone Calls and Follow-up Visits

If an opportunity for an information session or meeting does not exist, or if you have yet to reach all physicians in your community, contact the office staff of each local physician. A personalized visit or phone call to introduce CHAP to the office staff, followed up by a short meeting to further discuss CHAP with the physician. Send an information package including:

During the follow up visits, the Family Physician Recruitment Guide (Appendix 4.5) should be used to ensure all details are covered.

If a few physicians indicate that they still do not wish to participate, follow-up with them again. The numbers of participating physicians may persuade the non-participating physicians to reconsider CHAP at that time

Recruiting Other Primary Care Providers: Family Health Teams

CHAP is an established strategy for chronic disease prevention and management that embraces partnerships between primary care providers and resources in communities. Many Family Health Teams (FHTs) are engaged in or planning similar initiatives to serve their patients and communities. CHAP offers the necessary resources, tools and systems for primary care teams to offer a sustainable program to address risk factors for cardiovascular disease and other chronic diseases. Blood pressure and other risk factors assessed at CHAP sessions are common across multiple chronic diseases. CHAP provides education and self-help tools designed to involve patients in addressing modifiable risk factors. CHAP can be tailored to the expertise of providers and the needs of patients and the local community while maintaining its standardized components.

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6.3 Local Pharmacist Champion

At the outset of your pharmacy recruitment efforts, determine whether your community has a “pharmacist champion”. Similar to the local physician opinion leader, this person is the pharmacist who is viewed by their peers as being a leader in health issues.

Discussions with local physicians, the local public health unit, the local hospital administrator, the local lead organization, and CHAP Central will identify such an individual in your community.

Once you have identified a pharmacist champion, arrange a meeting to introduce them to CHAP and their role in establishing CHAP in your community. Ask the pharmacist champion to play a key role in the recruitment of pharmacists and pharmacies including:

    • Signing letters to local pharmacies.
    • Meeting with other pharmacists to encourage them to participate in CHAP.
    • Talking with other pharmacists about CHAP on an informal basis.
    • Delivering presentations at information sessions or meetings of other pharmacists in the area.

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6.4 Pharmacies and Pharmacists

Pharmacies are the main location of the CHAP sessions. The recruitment of pharmacies to participate in CHAP is important.

Finding Pharmacies and Pharmacists

There are several ways to find pharmacies and pharmacists in your community:

    1. The Phone Book: Look in the yellow pages and www.411.ca
    2. Internet Searches
    3. Local or provincial pharmacy associations
    4. The Local Public Health Unit
    5. Family Health Teams

Once you have a complete list of local pharmacies and pharmacists, record all contact information to enable you to recruit the pharmacists/pharmacies.

How to Recruit Pharmacies and Pharmacists

It is easier and more effective to contact each pharmacist personally to discuss CHAP. The following method has been found to be effective:

  • Call each pharmacy and arrange an appointment to discuss CHAP with the appropriate pharmacist or pharmacy owner.
  • Following each phone call, send a copy of the following:

During the meeting with the pharmacist or pharmacy owner:

  • Discuss CHAP in more detail.
  • Discuss and sign the Pharmacist Letter of Understanding (Appendix 5.3).
  • Review the CHAP Pharmacist Assessment Form (Appendix 5.2), CHAP Session Blood Pressure Recommendation Protocol (Appendix 4.4), and the Meds Check Program.
  • Determine the place within the pharmacy to hold the session, as well as the times and dates for CHAP sessions.
  • Ask whether the pharmacist would be willing to staple a copy of the CHAP session schedule to patient’s prescription bags.

After the meeting with the pharmacist or pharmacy owner:

  • Send a letter of confirmation to the pharmacists/pharmacy owners regarding their participation in CHAP and the schedule for CHAP sessions.
  • Advise the Local Lead Organization and collaborating organizations of recruitment progress.
  • Follow up with each pharmacy regarding CHAP session set-up.

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6.5 Community Health Nurse

Advertise in the community for a Community Health Nurse to work on an “ad hoc” basis.

The responsibilities of the Community Health Nurse include:

    1. Assist in the development and delivery of volunteer peer health educator training sessions and refresher sessions.
    2. Be available on-call during the CHAP sessions to respond to volunteer peer health educator questions and address urgent cases that require reassessment.
    3. Interact with health care providers on urgent participant needs as required.

See Appendix 1.2 for a Community Health Nurse Job Description.

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6.6 Volunteer Peer Health Educators

Volunteer Peer Health Educators are an integral part of CHAP. Their role is invaluable and contributes to the success of CHAP in each community.

Volunteers became involved in CHAP for one of the following reasons:

    1. Through a friend/word of mouth,
    2. Notice posted in the newspaper,
    3. Talk/contacted by local CHAP Coordinator,
    4. Contacted by agency,
    5. Notice board at a community venue.

This information is based on the 2006 top five CHAP recruitment methods for volunteers.

Recruiting volunteer peer health educators is an essential part of CHAP. Based on the current CHAP communities, volunteer responsibilities at CHAP sessions include:

  • Greet participants and help them to sign the consent form.
  • Assist participants with filling out the top portion of the Risk Profile Recording Form (Appendix 7.3), complete the risk profile, look up the pharmacist and physician, assist with measuring the participant’s blood pressure, and make recommendations based on CHAP Blood Pressure Reading Protocol.
  • Help out in all areas for sessions that are anticipated to be very well attended.

The number of volunteers needed to run the CHAP sessions in your community will depend on the number of participating pharmacies in your community, and the number of participating physicians.

For the purposes of CHAP, older adults are the best group from which to draw volunteer peer health educators for the following reasons.

  • Participants are comfortable with people their own age taking their blood pressure and conversing with them on health issues.
  • Older adults are part of the “target group” and as such volunteer peer health educators can act as ambassadors to the program with friends and family members who might also benefit from attending a blood pressure session.

Volunteers should be able to commit to attend training sessions.

How to Recruit Volunteer Peer Health Educators
  • Refer to your community profile for a list of groups to contact to recruit volunteers. These groups will include volunteer centers, senior community centers, and church groups.
  • Telephone each group. Follow up with a letter by fax or mail, which provides an overview of CHAP, the role of the volunteer peer health educators, and the expected commitment of volunteers.
  • Include an advertisement in the local newspaper with the Sample Volunteer Recruitment Poster (Appendix 2.6).
  • Distribute posters about CHAP in the various locations where older adults gather and include a tear-off telephone number and name for more information about CHAP.
  • Ask to be put on the agenda of speaking engagements to older adults where you can speak about CHAP and its opportunity for volunteers using Appendix 6.1Volunteer Recruitment Presentation.

As you recruit volunteers, record all contact information, including how they heard about CHAP. Once your list of peer health educators is confirmed, start to coordinate training sessions.

Volunteer Peer Health Educator Training Sessions

Training sessions must be held for volunteer peer health educators. More detailed information on training sessions is found in Planning for CHAP Sessions.

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7. Planning for CHAP Sessions


Objectives

    1. Hold information sessions/meetings with physicians and pharmacists and/or schedule office visits.
    2. Implement invitation strategies according to options selected by physicians.
    3. Hold training sessions with volunteer peer health educators.
    4. Develop a schedule of the CHAP sessions.

The planning for CHAP sessions will take from one to three weeks to complete. It will allow you to complete recruitment efforts, hold any information sessions, finish up with physician and pharmacy visits, hold volunteer peer health educator training sessions, contact patients as per physician’s requests, and make final preparations for the CHAP sessions.

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7.1 Information Sessions/Meetings

The Information Session Presentation in Appendix 3 is a sample PowerPoint presentation that can be modified for any scheduled information sessions and/or meetings in which information on CHAP is requested.

The following hand outs should be provided at face-to-face sessions/meetings:

Physicians:

Pharmacists:

Volunteer Peer Health Educators:



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7.2 Implement Invitation Strategies

Physicians can choose a combination of two options to make their patients aware of CHAP.

Option 1 Personalized invitation letters from the family physician (Appendix 4.6)
This is the recommended option.
Option 2 Community–wide CHAP advertising (Appendix 4.8)

As soon as a physician indicates how he/she would like his/her patients to be contacted to participate in CHAP, the local CHAP coordinator may begin the process for patient recruitment.

Option 1: Personalized invitation letter from family physician

The Local CHAP Coordinator will need to do the following to organize these letters.

    1. Obtain a list of high risk older adults patients from the family physician or office staff. These patients are community-dwelling older adults.
    2. Ask each physician to verify the list by crossing out individuals who are deceased or mentally and/or physically incapable of attending CHAP sessions in the community, or who reside in a hospital or Long Term Care Facility.
    3. Obtain letterhead from each family physician’s practice for the invitation letters. Appendix 4.6 contains a sample Invitation Letter to Patients.
    4. Ensure that the title of the person (example, Mr., Mrs., Miss) or the patient’s gender is indicated. This will ensure the letter is addressed appropriately.
    5. Obtain the physician’s electronic signature to place at the bottom of each letter.

Option 2: Community-wide CHAP Advertising

    1. Appendix 4.8 has a sample advertisement for local newspapers for community wide advertising.
    2. This same advertisement can also be posted in the community in participating physicians’ offices and public buildings according to your communications plan.
    3. The Local Lead Organization may also wish to send out media releases and/or public service announcements dependent on the communications plan.

Advertisements for the community will be generic in scope and will be written for the community-at-large. Ads are not specific to the site to which they are posted.

Regardless of the number of participating family physicians, community-wide advertising would still take place.

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7.3 Volunteer Peer Health Educator Training Sessions

The local CHAP coordinator will contact the volunteer peer health educators by telephone to confirm the dates of the training sessions. Participation in the training sessions is mandatory.

Training sessions should be held at a time to allow ample time for questions and hands-on experience with the automated blood pressure measuring device and the Risk Profile Recording Forms.

Appendices 6.1, 6.2, 6.3, and 6.4 contain PowerPoint presentations for each training session which can be downloaded and modified to best suit the needs of volunteers.

The community health nurse will lead the training sessions. The Local CHAP Coordinator should coordinate and be present at each session. This is an opportunity to continue to establish a rapport with the volunteers.

The topics to be covered during the training sessions include:

    • Overview of cardiovascular health issues
    • Background information on high blood pressure/hypertension
    • Healthy versus non healthy lifestyles
    • Modifiable versus non-modifiable risk factors
    • Details on the workings of the CHAP sessions
    • The role of the volunteer peer health educators
    • Review CHAP session set-up

Following the first training session, each volunteer must sign a CHAP Volunteer Peer Health Educator Letter of Understanding (Appendix 6.5) in order to continue to participate in the Program. The local CHAP coordinator will confirm with the volunteers that the schedule of CHAP sessions.

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7.4 Schedule of CHAP Sessions

The CHAP session schedule is a priority, and a well organized schedule is necessary for the successful operation of the CHAP sessions.

We suggest CHAP sessions are scheduled in the morning for the following reasons:

  • Holding all sessions at a designated time of day helps to improve the accuracy of the blood pressure readings. Given that blood pressure tends to fluctuate throughout the day, a standardized schedule for to take readings is necessary.
  • CHAP pilot studies revealed that the majority of participants preferred morning sessions.

When developing the schedule, keep in mind that all pharmacies do not open at the same time. Coordinators need to be at each session 15 minutes prior to the session start time and will have to be aware of each pharmacy’s regular business hours.

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7.5 Preparing the CHAP Session Schedule

The following is a step-by-step process to preparing the CHAP session schedule.

Step 1 Map out the sessions on a spread sheet.
Step 2 Confirm session dates and times with the pharmacies and/or pharmacists.
Step 3 Assign volunteer peer health educators to each session according to their availability.
Step 4 Send letters of invitation to patients as the dates and times are confirmed by the pharmacists.
Step 5 Contact the local newspapers and forward the schedule/advertisement for inclusion in the paper.
Step 6 Send out press releases to all local media (print, radio and television) which outlines the schedule and an invitation for the general public to attend.
Step 7 Post posters of the schedule around the community where seniors gather.
Step 8 Send a copy of the schedule to the following: Regional Manager, family physicians, pharmacies, local lead organization, community health nurse, all volunteer peer health educators and all health and social service organizations.


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8. Implementing CHAP Sessions


Objectives

    1. Prepare CHAP Session Forms for CHAP Sessions.
    2. Obtain health promotion resources for CHAP participants.
    3. Prepare CHAP Session set-up.
    4. Prepare for information management of blood pressure readings and health information of CHAP session participants.

Before you precede with the implementation of CHAP sessions in your community during weeks 12 to 22, ensure that the following has been done:

All, if not the majority, of local physicians, have agreed to participate in CHAP.
Pharmacists and pharmacies have been recruited.
Letters of Understanding have been signed for participating pharmacies, and volunteer      peer health educators.
Family Physician Letter of Understanding has been signed by participating physicians.
Participant letters have been mailed on behalf of physicians.
Community-wide advertising has taken place or is underway. (Press releases sent,      advertisements placed and posters distributed throughout the community.)
A list of participating physicians and pharmacies has been faxed to Clinforma and codes      have been assigned to each one.
All participating physicians and pharmacists have received the CHAP Session Blood      Pressure Recommendation Protocol.
The required number of volunteer peer health educators has been reached.
Volunteer peer health educators have been trained and matched with CHAP sessions.
Site visits to each of the pharmacies have been done and a list of the necessary      equipment (tables, chairs, markers, etc.) has been made.
A schedule for CHAP sessions has been completed and received by all volunteer peer      health educators, participating physicians and pharmacies, the community health nurse,      and the local lead organization.


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8.1 CHAP Session Forms

At each CHAP session, the following forms need to be available:

  • Participant Sign-in Sheet (Appendix 7.1)
  • Participant Consent Form (Appendix 7.2)
  • Risk Profile Recording Form (Appendix 7.3)
  • CHAP Session Blood Pressure Recommendation Protocol (Appendix 4.4)
  • Mentorship Discussion Form (Appendix 7.10)
  • CHAP Session Schedule (one for posting and other copies in case the pharmacist is willing to staple the schedule to patient’s prescription bags.)
  • Name tags for volunteer peer health educators and Local CHAP Coordinator (Appendix 7.6)

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8.2 Health Promotion Resources for CHAP Sessions

The health promotion resources need to reflect the resources made available to participants that address the modifiable risk factors for heart disease and stroke. There are a number of sources for these resources in your community, including:

  • Local Public Health Unit
  • Local parks and recreation programs
  • Local YWCA
  • Local branch of the Ontario Heart and Stroke Foundation, Kidney Foundation and Diabetes Association

Appendix 7.11: Finding Health Promotion Resources has suggestions on where to got to find health promotion resources in your community. The resource section on the CHAP website: www.chapprogram.ca also has a number of health promotion links and resources available.

It is important to have health promotion materials that cover all of the modifiable risk factors for heart disease and stroke; for example, healthy eating, physical activity and smoking cessation. The purpose of providing these resources to CHAP participants is not the quantity given to participants but the resources that reflect the individual needs of each participant and their personal objectives.

The Heart and Stroke Foundation has a valuable wallet-sized information piece entitled, Get Stroke Smart! It outlines the warning signs of a stroke and can be found in Appendix 7.7. Copies of this resource should be on-hand at each session. In addition, the Blood Pressure Basics Information Sheet (Appendix 7.7) should be made available at sessions.

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8.3 CHAP Session Set-Up

Each pharmacy or community location for CHAP sessions will be set up differently given that the space allotted to CHAP will vary. As well, other events or promotions may be taking place in the pharmacy at the same time as CHAP. Be prepared to set up in a different area of the pharmacy if possible, since there is a need to privacy for participants.

The flow of participants through the CHAP session needs to be taken into account before setting up the session. The following is just one example of how a CHAP session can be set up:

Each CHAP session should have: a greeting station, waiting area and blood pressure station. Local CHAP Coordinators should arrive at each session at least 20-30 minutes early to set up each session.

The following is a list of some of the items that will be needed at each session:

Automated Blood Pressure
Measuring Device
CHAP Forms
Tables
Chairs
Education Materials
Pens
Pad of Paper
Sticky notes
Tape to Mount Poster
 Poster
Forms
Name Tags
Correction Tape
Power bars and extension cords
Duct tape
Clipboards
Binder/Container for completed forms
Extra copies of the schedule


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8.4 Information Management

The blood pressure readings and health information collected at each session must be handled appropriately to ensure privacy and confidentiality. Any form or document containing participant information that is not to be kept and is intended for disposal must be shredded and not put into the garbage.

Protocol for Blood Pressure Readings

Appendix 4.4 outlines the CHAP Session Blood Pressure Recommendation Protocol. The community health nurse, the Local CHAP Coordinator, and all volunteer peer health educators should be well versed on the protocol. Participating physicians and pharmacists should have been given an opportunity to review the protocol by this point.

The community health nurse must have a pager or cell phone throughout the sessions so that she/he can be reached at all times for cases requiring nurse intervention.

Risk Profile Recording Form

The Risk Profile Recording Form comes in triplicate copy.

  • Once it is completed, the participant is given the pink copy.
  • At the end of the session, fax all white copies into Clinforma. If the participant has not given consent for the information to be sent to his/her family physician, the computer will not generate a report.
  • Fax the forms in batches of 10 to the toll-free Clinforma number that has been provided by the Regional Manager.
  • After faxing the white copies to Clinforma, place these white copies into a binder or container to ensure that participant health information is stored in a confidential manner.
  • The yellow copies can be mailed or hand-delivered to local pharmacies, as per the participant’s consent.

Instructions for the completion of the Risk Profile Recording Form can be found in Appendix 7.4. Appendix 7.5 includes a checklist to assist the Local CHAP Coordinator to avoid common risk profile recording form errors.

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10. Sustaining CHAP

The CHAP Working Group would like to see many CHAP communities continue to offer CHAP within their communities. In order to maintain the integrity of CHAP, the following components are essential to its ongoing operation.

  1. Community Wide
    • CHAP must be a community-wide program, offered free of charge to older adult community residents.
  2. Setting
    • Communities must hold at least one regular CHAP session a month in a local pharmacy. Additional sessions may be held in other settings where a health care professional will be present. For example, local public health units, local health agencies such as VON or CCAC, medical clinics, and seniors centre.
  3. Collaboration with Primary Health Care Providers
    • CHAP connects community-based health promotion and prevention activities for older adults with the care provided by their family physician and pharmacist.
    • The majority of family physicians and other primary care practitioners need to be involved with CHAP in referring or inviting patients to participate in CHAP.
    • Other health professionals such as nurse practitioners, pharmacists, and dietitians should also be encouraged to invite or refer patients and/or become involved in CHAP in other ways.
  4. Self-Blood Pressure Measurement
    • At each CHAP session visit, participants must measure their blood pressure, with assistance from a volunteer, using an automated blood pressure measuring device such as the BpTRU™. It is then recorded on the Cardiovascular and Stroke Risk Profile Form.
  5. Information Management
    • Clinforma Database Management is an essential component of CHAP. The continued use of Clinforma services ensures the following:
      • a. Feedback of Results to Family Physicians: Clinforma transfers CHAP session results to primary health care providers with participant consent. It does so for high risk participants using the CHAP protocol and for all participants using the CHAP summarized participant results report form.
      • b. Evaluation: Clinforma collects data for the purpose of ongoing evaluation and quality improvement
    • The use of Clinforma allows for continued program monitoring and improvement. It is necessary to maintain the support of family physicians and the integrity of CHAP in their view. It secures family physician support and the recruitment of participants through family physicians is made easier. This step also ensures effective monitoring of blood pressure and appropriate care and follow up for participants.
  6. Follow-up of High Risk Participants
    • Blood pressure and Cardiovascular Disease and Stroke Risk Profile results for each participant at each session visit should be evaluated based on the CHAP Session Blood Pressure Recommendation Protocol. In doing so, it will ensure that CHAP session participants receive the appropriate follow-up from their health care providers.
  7. Health Promotion Education
    • CHAP participants will receive their Blood Pressure and Cardiovascular Disease and Stroke Risk Profile results at each CHAP session. CHAP participants can then take home a copy of these results and give their permission to have them shared with their family physician and pharmacist. This allows physicians and pharmacists to follow-up with their patients if required.
    • CHAP participants will also receive targeted education resources that include referrals to local programs so that they may reduce their risk of cardiovascular disease and stroke. Some communities may offer healthy living education sessions for CHAP participants.
    • Healthy living resources should be available for distribution at CHAP sessions that address a wide variety of topics, including healthy eating, smoking cessation and physical activity. Linkages to local, provincial and national sources of health promotion information and programs should also be provided.
  8. Continuous Program Evaluation
    • Conducting continuous program evaluation in your community will enable the Local Lead Organization and the Local CHAP Coordinator to monitor the progress of CHAP. This will help to determine local successes/challenges and impact of CHAP on your community.
    • In order to evaluate CHAP in their community, the Local Lead Organization or Local CHAP Coordinator, should track the following:
      1. a. Number of CHAP sessions held;
      2. b. Total number of blood pressure assessments conducted;
      3. c. Total number of unique participants;
      4. d. Average number of visits per participant;
      5. e. Total number of participating family physicians, pharmacists and other health care professionals, and;
      6. f. Total number of trained volunteer peer health educators

Making the Case for CHAP

In 2006, the CHAP Working Group undertook a community level randomized control trial of 20 communities in Ontario. These randomly selected communities had populations between 10,000 and 60,000 individuals. The implementation of CHAP was successful in all 20 communities. Overall, there was a high level of community engagement in CHAP indicated by the participation of 99% of all family physicians and 89% of all pharmacies. CHAP participants liked the program as demonstrated by the number of repeat visits to CHAP sessions. In total, 43% of all CHAP participants returned for a repeat visit. The mobilization of these communities was achieved in part by the use of the CHAP Implementation Guide. The guide presented the steps required to implement CHAP in a consistent manner across all of the communities. The CHAP Implementation Guide contained rationale, program objectives, and templates for letters, power point presentations, job descriptions, volunteer training materials and advertising. For more information about this study, please see www.procor.org/research/research_show.htm?doc_id=1090642.

Annual Cost to Operate CHAP

Here is a draft budget that includes an overview of the approximate costs of sustaining CHAP for one year in your community.

Manual Data Checking

An estimate of the cost of automated processing of faxed-in paper forms without manual data checking is based on your individual community statistics. In (community), you averaged (X) clients per month last year. At $0.50 per form, we estimate your cost for automated processing of faxed-in paper forms without manual data checking would cost approximately ($).

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11. Ontario's Chronic Disease and Prevention Management Framework and CHAP

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.
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