Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes?

Provost, Sylvie; Pineault, Raynald; Grimard, Dominique; Pérez, José; Fournier, Michel; Lévesque, Yves; Desforges, Johanne; Tousignant, Pierre; Silva, Roxane Borgès Da

doi:10.24095/hpcdp.37.4.01

Cited by 14 publications

(18 citation statements)

References 22 publications

(26 reference statements)

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“…Of these, 13 records were excluded for having 3 or fewer health professions or no usable outcome measures, leaving 50 articles retained in the systematic review. A final 39 studies were included in the meta-analysis 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 after 11 studies were excluded because of inadequate data (eTable in the Supplement ). 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 Figure 1 depicts the inclusion process of the systematic review and meta-analysis.…”

Section: Resultsmentioning

confidence: 99%

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Assessment of Interprofessional Collaborative Practices and Outcomes in Adults With Diabetes and Hypertension in Primary Care

et al. 2021

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IMPORTANCE Interprofessional collaborative practice (ICP), the collaboration of health workers from different professional backgrounds with patients, families, caregivers, and communities, is central to optimal primary care. However, limited evidence exists regarding its association with patient outcomes. OBJECTIVE To examine the association of ICP with hemoglobin A 1C (HbA 1c), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels among adults receiving primary care.

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Section: Resultsmentioning

confidence: 99%

“…Zwar et al, 62 2007 Provost et al, 59 2017 230 992 -0.17 (-0.30 to -0.04) -0.12 (-0.19 to -0.04) .00 .01…”

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confidence: 99%

Assessment of Interprofessional Collaborative Practices and Outcomes in Adults With Diabetes and Hypertension in Primary Care

et al. 2021

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“…Previous studies on prevention in the primary care sector have mostly focused on either health checks or behaviour-change counselling [48–50]. However, recent studies report on interesting, though inconclusive, results on linking primary care and community health [51, 52]. Our findings suggest that personal digital health profiles may be a valuable asset in the recruitment of patients to preventive programs across primary care providers.…”

Section: Discussionmentioning

confidence: 69%

Step-wise approach to prevention of chronic diseases in the Danish primary care sector with the use of a personal digital health profile and targeted follow-up – an assessment of attendance

et al. 2019

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Background Current evidence on chronic disease prevention suggests that interventions targeted at high-risk individuals represents the best way forward. We implemented a step-wise approach in the Danish primary care sector, designed for the systematic and targeted prevention of chronic disease. The intervention centered on a personal digital health profile for all participants, followed by targeted preventive programs for high-risk patients. The present paper examines individual characteristics and health-care usage of patients who took up the targeted preventive programs in response to their personal digital health profile. Methods A sample of patients born between 1957 and 1986 was randomly selected from the patient-list system of participating general practitioners in two Danish municipalities. The selected patients received a digital invitation to participate. Consenting patients received a second digital invitation for a personal digital health profile based on questionnaire and electronic patient record data. The personal digital health profile contained individualized information on risk profile and personalized recommendations on further actions. If at-risk or presenting with health-risk behaviour a patient would be advised to contact either their general practitioner or municipal health centre for targeted preventive programs. Attendance at the targeted preventive programs was examined using Poisson regression and chi-squared automatic interaction detection methods. Results A total of 9400 patients were invited. Of those who participated (30%), 22% were advised to get a health check at their general practitioner. Of these, 19% did so. Another 23% were advised to schedule an appointment for behaviour-change counselling at their municipal health centre. A total of 21% took the advice. Patients who had fair or poor self-rated health, a body mass index above 30, low self-efficacy, were female, non-smokers, or lead a sedentary lifestyle, were most likely to attend the targeted preventive programs. Conclusions A personal digital health profile shows some promise in a step-wise approach to prevention in the Danish primary care sector and seems to motivate people with low self-efficacy to attend targeted preventive programs. Trial registration Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016 ). Prospectively registered on the 29th of April 2016.

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“…Care coordination benefits have not been well quantified but some data from medicine have demonstrated benefits for patients. 5 Data elements associated with guidelines include risk scoring for caries, periodontal disease and oral cancer, rate of intervention recommendation activity (including specifically fluoride and sealants by age and caries risk) for patients at risk for caries, periodontal disease, and oral cancer. Also reported are prescribing practices of both opioids and antibiotics.…”

Section: Discussionmentioning

confidence: 99%

Creating systems aligned with the triple‐aim and value‐based care

Gesko

Worley

Rindal

2020

J Public Health Dent

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HealthPartners is an integrated health care system in the upper Midwest striving to provide value-based care that aligns with the triple-aim care. The dental delivery system at HealthPartners is focused on prevention by utilizing risk assessment tools (caries, periodontal disease, and oral cancer) built in to our record system. Integration with medical delivery system is facilitated by a shared electronic health record. Measurement is critical to determining if we accomplish our goals. The dentist compensation system is aligned with our care agenda. Implementation strategies, lessons learned, and future directions are discussed in the context of journey to achieve the triple-aim and value-based care. Clinic name HealthPartners Dental Group.

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Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes?

Abstract: Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

Cited by 14 publications

References 22 publications

Assessment of Interprofessional Collaborative Practices and Outcomes in Adults With Diabetes and Hypertension in Primary Care

Assessment of Interprofessional Collaborative Practices and Outcomes in Adults With Diabetes and Hypertension in Primary Care

Step-wise approach to prevention of chronic diseases in the Danish primary care sector with the use of a personal digital health profile and targeted follow-up – an assessment of attendance

Creating systems aligned with the triple‐aim and value‐based care

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