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Poster Abstracts

Exploring Successful Implementation of Team-Based Care in Chronic Disease Management: A Case Study


Madelyn daSilva ,

University of Western Ontario, CA
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Shannon Sibbald,

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Vaidehi Misra

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Integrated models of team-based care have become more common in Canada and are recognized as necessary to effectively manage complex chronic diseases, such as chronic obstructive pulmonary disease (COPD). Little is known on how to support the scale-up and expansion of successful models. This research explores the scale-up and spread of the Best Care COPD program (BCC), an evidence-based integrated model of team-based care for COPD that has been successfully implemented into primary care across Southwestern Ontario. BCC is delivered by trained Respiratory Therapists and is aimed to improve patient outcomes for those with COPD. Aims Objectives Theory or Methods

The objective of this study was to explore the mechanisms that enable scale-up of and support the sustainability of integrated models of team-based care. In collaboration with BCC program designers, we conducted a case study to explore these processes within the BCC program. Through an integrated knowledge translation (IKT) approach, this research includes focus groups, interviews, and ‘implementation logs’. Through iterative and continuous data analysis, this study aims to support and facilitate scale up and spread of the BCC program across the province and other similar chronic disease management sites.

Highlights or Results or Key Findings

BCC has been successfully implemented into 50+ primary care sites across Southwestern Ontario. Our findings identified three implementation phases; the pre-implementation phase, implementation, and the scale & sustainability phase. Our findings highlighted three foundational mechanisms integral to implementation across the different phases: 1) an evidence-based program 2) readiness to implement, and 3) peer-led implementation team. These primary mechanisms were supported through three transformative mechanisms including an adaptive delivery, provider empowerment, and embedded evaluation. Additionally, these findings were further support through four supporting mechanisms: provider training, administrative support, role clarity, and patient outcomes. Based on the interplay between these processes across the implementation phases we developed a framework which can inform implementation of integrated, team-based care for chronic disease in various contexts.


This research can support further program expansion by placing appropriate focus on the mechanisms that matter most: an evidence-based program, readiness to implement, and a peer-led implementation team. BCC is currently used to support the management of COPD, however, findings strongly support the applicability to other chronic disease management programs.

Implications for applicability/transferability sustainability and limitations

Future research on this program will explore the mechanisms that enable program sustainability. We acknowledge that one limitation of our current research is the lack of patient engagement. We plan to utilize an IKT approach in the next stage of our research to co-design our study with our patient representative.

How to Cite: daSilva M, Sibbald S, Misra V. Exploring Successful Implementation of Team-Based Care in Chronic Disease Management: A Case Study. International Journal of Integrated Care. 2022;22(S2):130. DOI:
Published on 16 May 2022.


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