Spread and Sustainability of Integrated Models of Team-Based Care for the Management of Chronic Obstructive Pulmonary Disease: A Multi-site Case Study

The prevalence of chronic disease represents a significant burden for the Canadian health care system. Chronic Obstructive Pulmonary Disease (COPD) is a chronic condition that effects lung function and reduces the quality of life for nearly 5% Canadians. Care for patients living with COPD can be improved through the use of integrated models of team-based care. These models involve coordination of services across providers to deliver better care for patients, caregivers and families. Integrated models of team-based care involve multiple healthcare professionals working together to provide appropriate care for patients. The aim of this research is to gain a better understanding of how successful integrated models team-based care are spread to new contexts and how these models are sustained over time, to ensure benefits are maintained. The objectives of this research are: (1) explore the spread of integrated models of team-based care for COPD, (2) explore the sustainability of these models, and (3) create a framework to support future efforts to spread and sustain these models. The study will be conducted in three years and will use mixed methods (surveys, observations, and focus groups). The expected outcomes of this study will be a description of how integrated models of team-based care are spread and sustained in different contexts along with an in-depth understanding of the barriers and facilitators to these processes. Our research will provide guidance of policymakers wanting to improve in chronic disease management. We will also offer a common language for research and practice, and support the best care for patients and caregivers.