1.

There is a need for a more coordinated approach to service planning and delivery
between AHS, PCNs and community organizations to improve access, reduce
duplication, promote integration and clearly define roles. Champions in each of these
sectors, at the provincial and local level, are required to lead the design and
implementation of the model. There is a need to define a governance structure to
support a coordinated approach to planning, implementation and operations.
2. Each of the stakeholder groups acknowledges the need for building partnerships for
successful program planning and delivery. There is an opportunity to optimize
infrastructure, capacity, resources and communication strategies through partnerships
3. The multi-disease approach has been successfully delivered in Alberta communities
with stated benefits including: improved resource management and reduced
duplication of
services, improved access to programs, and a more patient-centric approach. However,
there are still instances of disease-specific programs operating in parallel, requiring a
paradigm shift to engage physicians, specialty groups, funders and community
organizations in the value of the multi-disease approach.
4. Human resource challenges across sectors indicate the need for a strong provider
education strategy, ongoing mentorship and exploration of innovative human resource
approaches such as work to full scope of practice, interprofessional care models, and
alternative care providers, especially in remote locations.
5. The model should include recommendations for funding, including possible funding
sources and fee structures.
6. There is a need for a common evaluation framework and support provincially to
analyze
and report the evaluation results.
7. There is a need for local planners to systematically assess the needs of diverse and
vulnerable populations who face challenges accessing the mainstream programs and
utilize targeted approaches to improve access for these groups.

Population Needs Assessment
A population needs-based approach will be employed to assess population needs, the
determinants of health, chronic disease prevalence and chronic disease risk factors; with a
goal
of matching services to needs, thereby improving the health of the whole population and
reducing inequities in health. Two strategies will be employed in assessing the population
needs: mapping current CDM AHS, PCN and community services against the prevalence of
chronic conditions in a geographic area or Zone; and application of the Community
Assessment
& Service Response (CASR) within the Community & Rural Planning Framework. In addition
to
these specific strategies, the knowledge of local needs and resources possessed by the
community and Zone partners must be considered when determining location of programs
and
services.
Mapping CD Prevalence and CDM Services
Geographic Information System (GIS) mapping software is utilized to map out service
location,
by postal code, overlaid with disease prevalence, in order to match potential need to
services
and to identify potential gaps in services. (See Appendix 3)
Chronic disease prevalence will be identified by the Data, Integration, Measurement &
Reporting portfolio (DIMR). Data will be provided at the level of the Aggregate Local Area
(approximate population of 15,000) or at the Health Status Assessment Area level (66 areas
in
Alberta). Chronic diseases will be identified by Clinical Risk Groups (CRGs), including CRGs
for
diabetes, obesity, cardiovascular diseases, mental health and respiratory diseases.
The availability of CDM services within a Zone or community was assessed through the
environmental scan described earlier in this document. The mapped CDM service include
general health and disease-specific education, self-management support and physical
activity
programming; by sector (AHS, PCN and Community).