INNOVATION FUND Innovation, Integration, & Implementation Chronic Care and Patient Centred Care SHOWCASE 2016 INNOVATION FUND Innovation, Integration, & Implementation Chronic Care and Patient Centred Care SHOWCASE 2016

Regional Rheumatology Strategy: Facilitating Patient Access to Multidisciplinary Care

Chronic Care and Patient-Centred Care


Sherry Rohekar

519-685-8500 ext. 61243



Transformation: Health care is being delivered in a team model rather than as individual experts working separately.  This fosters collaborations between primary care, specialists, nurses, physiotherapists and occupational therapists. Adoptability:  Use of telecommunication and electronic communication make this model highly adaptable to different institutions. Outcomes:  Improved quality of patient care and reduced patient burden of frequently travelling to a tertiary care centre.


Background:  Southwestern Ontario is under-serviced for rheumatology and arthritis is a common cause of morbidity.  Improving rheumatology knowledge and skills of Nurse Practitioners (NP) in our region and utilizing telemedicine for our patient education will create a better model for chronic disease management.

Methods:  The project included two phases.  Phase I included a needs assessment to determine the educational needs of NPs in primary care and provided knowledge in Rheumatology.  Phase II included clinical skills training.  We partnered with NPs in the Grey-Bruce area to pilot a continuing education package.  Phase I.  A curriculum for NPs was created.    Participants completed feedback and pre-post disease management knowledge scores.    Phase II.  The second phase was directed at enhancing the skills of Phase I completers.  This phase included a centralized preceptorship program and clinical internships at our center to prepare NPs to co-manage patients with rheumatic diseases.

Results:  A curriculum was disseminated to a multidisciplinary care teem.  Seventeen webcasts were delivered.  Pre- and post-program knowledge assessments were completed.  Participating NPs also performed pre- and post-program chart reviews.   We developed an Annual Rheumatology Update Day.  Nurse practitioners from within our referral area participated in local preceptorships.  A rheumatologist and psychologist travelled to Chatham to give didactic lectures and develop a plan to facilitate patient care.

Conclusions:  The project was presented at two international conferences.

Future:  We proposed further collaboration with the Owen Sound and Goderich sites.  Both sites were interested in linking to St. Joseph’s rheumatology via the telehealth network.

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