Comorbitdity clinical trials

TRANSforming InTerprofessional Cardiovascular Prevention in Primary Care

The TRANSIT program is a program to TRANSform InTerprofessional clinical practices to improve cardiovascular prevention in primary care. It addresses priorities in primary care relevant to the Chronic Care Model (Wagner 2001): self-management support, delivery-system design, and management of clinical information. The program includes : - a case manager to coordinate and provide care and follow up; - clinical protocols and tools to support interprofessional and systematic follow up; - training for clinicians; - patient's personalized cardiovascular health booklet; - tools to promote group sessions for patient education on cholesterol, hypertension, and diabetes. The general OBJECTIVE of this trial is to evaluate and compare two STRATEGIES for implementing the TRANSIT program in Family Medicine Groups (FMGs): 1. facilitation, and 2. passive diffusion. Passive diffusion is the usual strategy where clinicians implement an intervention program by themselves. Facilitation is a strategy whereby a facilitator provides support to a team of clinicians to help them introduce the changes required to implement the program into practice. The hypothesis is that facilitation will be more efficacious to implement the program than passive diffusion: - it will enhance the provision of cardiovascular preventive care; - it will enhance interprofessional collaboration; - it will enable more efficaciously the implementation of new clinical processes; - it will improve patient clinical outcomes; - it will cost more in the short term, but will have positive economic impact in the long term; - there will be less "undesired effects" of all types related to implementation. To test the hypothesis, we assess the efficacy of the implementation strategies to enhance interprofessional collaboration and better support patients in the management of their conditions. Impact on provision of care, interprofessional collaboration, clinical processes, and patient clinical outcomes (values, therapeutic targets, and lifestyle habits) will be evaluated. Moreover, the implementation cost related to each strategy will be estimated. We complement the trial with qualitative methods to document the perceptions of clinicians, facilitators, patients and members of the family regarding the TRANSIT program, the implementation strategies and the observed changes in the clinical practices and outcomes.