Table 1 Characteristics of the interventions

CDPM practitioner training

Theoretical training on:

− Motivational interviewing

− Function of the respiratory system

− Function of the cardiovascular system

− Diabetes

− Risk factors

− Existing CDPM services

Practical training:

− Three-week mentoring in specialized CDPM services facilities.

Preliminary clinical evaluation

The clinical evaluation of participants includes:

− Anthropometric characteristics

− Medical history

− Medication

− Functions (respiratory, cardiovascular, endocrine, gastro-intestinal)

− Lifestyle habits and risk factors

− Patient preoccupations and objectives

− Previous interventions (nutrition, physical activity, respiratory, smoking cessation)

− Recent changes (weight, alcohol consumption)

Disciplines involved in the intervention

The interventions, based on a referral from a family physician or nurse, are provided by professionals in the following disciplines:

− Clinical coordination

− Nursing

− Physical activity therapy

− Nutrition

− Respiratory therapy

− Smoking cessation therapy

Implemented interventions

The interventions implemented are:

− Self-management support

− Education on diseases (diabetes, COPD, asthma, cardiovascular)

− Education on risk factors (pre-diabetes, high blood pressure, dyslipidemias, obesity, physical inactivity, smoking)

− Counseling on medication

− Motivational interviewing

− Education about nutrition

− Education about physical activity

− Counseling on smoking cessation

Tools and support material

Each intervention is supported by print and other material to ensure that patient engagement is maintained even between the interventions. These include documents on:

− Chronic disease management

− Asthma, COPD

− Diabetes

− Cardiovascular

− Metabolic syndrome

− Hypo/hypertension

− Tools for smoking cessation

− Stress management

− Blood pressure monitoring journal

− Personal objectives journal

− Physical activity journal

Communication & coordination

The CDPM practitioners in our study work within primary care settings which enhances communication with primary care physicians, nurses and staff. The clinical coordinator ensures optimal communication and transition of care between the project team, the primary care professionals and specialized services. Special attention is given to the distinction of tasks fulfilled by project CDPM practitioners and tasks fulfilled by primary care nurses.

Integration

Prior to the implementation of interventions, a pre-implementation evaluation is conducted to identify the needs for CDPM services and the contextual factors of the participating PC clinics in the follow-up of CD patients. The pre-implementation evaluation of the project promotes the sharing of a common positive vision of an intervention that focuses on prevention, earlier support for patients in the course of their disease, interprofessional collaboration, services integration, motivational interviewing and self-management support.

Participating primary care professionals

Participating primary care professional include:

− Family physicians (63)

− Nurses (5)

Participating primary care settings:

− Four (4) clinics

− Four (4) family medicine groups

Participating specialists

Participating specialists include:

− Cardiologists

− Internal medicine specialists

− Endocrinologists

− Pneumologists