New study aims to understand team-based care for chronic disease management

Chronic diseases, such as chronic obstructive pulmonary disease (COPD), are complex and require thorough care to help manage the condition. Patients often need support from an integrated team of health care professionals who work in different settings. 

Dr. Shannon Sibbald, associate scientist at Lawson Health Research Institute, is leading a study to better understand integrated health care teams for chronic disease management and factors that help successful implementation. 

Integrated team-based models of care include multiple health care providers working together to support patients with complex needs, such as those with chronic disease. There are many benefits to integrated team-based models of care. Patient outcomes are improved, health care providers feel more supported in their work and services are less likely to be duplicated. 

Dr. Sibbald’s research focuses on chronic obstructive pulmonary disease (COPD), a devastating chronic disease affecting normal lung function in over 1.5 million Canadians. COPD is one example of a chronic disease where patients can benefit from team-based care. COPD is often underdiagnosed, and patients with COPD and other chronic diseases may not be receiving the ideal care for their condition. 

While integrated team-based care is important, there are currently few studies to guide implementation. In this study, Dr. Sibbald’s research team will engage health care providers and patients to gain a rich understanding of successful integrated approaches to chronic disease management, including how team-based models of care are implemented. The team will also work to better understand how patients with chronic diseases view such models, and what their hopes and expectations are for their care. 

“We want to explore innovative and successful approaches to implementing team-based models of care,” explains Dr. Sibbald. “We’re looking to learn how these methods can support practice, improve patient outcomes and spread innovation.”

The team will look at high performing integrated care teams that support current best practices at a family health team in London, Ontario. 

When models are applied to practice, context is an important part to consider. For chronic diseases, context is often broad and elaborate. They hope to gain insight into what works well and what does not in dynamic contexts, and gain a better understanding of implementation facilitators and barriers.

The ultimate goal is to build knowledge that will support implementation and sustainability of high-performing integrated health teams across our health system.

“While motivation and momentum to use integrated teams is high, there is little guidance on how to do this well,” says Dr. Sibbald. “This research will provide insight into what works and what does not, reducing our gap in knowledge.”

Dr. Sibbald received a Lawson Internal Research Fund (IRF) grant to conduct this pilot study. Once complete, Dr. Sibbald’s team hopes to expand the study to look at integrated care models at other sites across the province. 

"The IRF grant enables our team to validate our methods of evaluating the implementation of interprofessional team-based care in complex settings," adds Dr. Sibbald. "By examining the impact team-based care for patients with COPD, we hope to demonstrate the relevance of our findings, to support grant proposals."

The IRF is designed to provide Lawson scientists the opportunity to obtain start-up funds for new projects with the potential to obtain larger funding, be published in a high-impact journal, or provide a clinical benefit to patients. Funding is provided by the clinical departments of London Health Sciences Centre and St. Joseph’s Health Care London, as well as the hospital foundations (London Health Sciences Foundation and St. Joseph’s Health Care Foundation).