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Thursday, December 27, 2012

Filling the CPG production-utilization gap: The Spinal Cord Injury Knowledge Mobilization Network

Dr. R. J. Riopelle, McGill University; Scientific Director 

The launch of the Health Council of Canada CPG video series is a welcome and timely contribution to the directions emerging from the November 2011 Canadian Clinical Practice Guidelines (CPG) Summit. This series will continue to nurture a growing national effort to design, disseminate and utilize CPGs across Canada. That said, there remains a notable gap between the design of these guidelines and their utilization in clinical settings.

The Spinal Cord Injury Knowledge Mobilization Network (SCI KMN) is an emerging knowledge mobilization initiative with a stakeholder-driven agenda to standardize care for secondary complications associated with SCI using contemporary evidence-based CPGs in rehabilitation centres across Canada.

SCI KMN is a Community of Practice composed of 6 rehabilitation sites in 3 provinces (AB, ON, QC) that is steered by the Ontario Neurotrauma Foundation Knowledge Curator (ONF KC) and supported by a public (health jurisdictions) - private partnership. In this regard, SCI KMN activities map precisely to the Health Care Innovation Working Group of the Council of the Federation provincial and territorial-specific deployment strategy.

The Network is composed of Knowledge Producers, Knowledge Users (providers), and End Users (patients) engaged in participatory research that directs itself to the goal of a health transformation value equation - a patient outcomes numerator, and a provider performance/resource utilization denominator. Outcomes and performance data is captured in site quality scorecards, and in a global data collection platform to inform continuous quality improvement for national care standardization.

A 2010 community survey by the Rick Hansen Institute (RHI) determined that the most urgent secondary complications associated with SCI that needed to be addressed were in the areas of pressure ulcer prevention and management, pain management, and urinary bladder management. To respond to these needs, SCI KMN Phase 1 was launched in early 2011 using contemporary CPGs as part of an integrated package of ‘causal factors’ directed to building institutionalization of, and innovation capacity for, standardization of care.

SCI KMN Phase 2 (2013-2018) contemplates expansion of the Community of Practice to two additional provinces (BC, NB) and scaling of activities across the care continuum, involving eight rehabilitation sites with the potential to access 80% of SCI patients in Canada. Building on its ‘by the people, for the people, no stone unturned’ approach, Phase 2 activities will embrace a Community of Innovation to enrich its causal factors package in response to participant demand: a health system adapted implementation guide, decision support tools for patients and providers, an innovation broker training program, and introduction of Patient Reported Outcomes into the patient practice portfolio, all in the interests of optimizing patient outcomes/impact for social and economic benefit, and provider performance/resource utilization for economic benefit.

Consensus among providers and patients that CPGs are an essential part of the health quality agenda represent a necessary ingredient for care standardization. However, the necessary and sufficient conditions for filling the CPG production-utilization gap directed to making a difference requires a ‘developmental causal factors approach’ such as referred to above.

Thursday, December 20, 2012

Consider this: Canadian Blood Services as a model for pan-Canadian health care service delivery

Dr. Graham Sher, Chief Executive Officer, Canadian Blood Services

There has been much written and said about our ailing health care system, including comments such as: "It is not sustainable and not affordable,” or "If only the federal, provincial and territorial governments could get their act together, all problems will be solved.”

In a series of talks I have been doing at the Economic Club of Canada, I have been addressing one important aspect of what I believe is necessary to help transform the system.

Health care delivery is clearly the jurisdictional responsibility of provincial and territorial governments. The federal government has a role to play in funding, in standards setting, in overseeing the principles of the Canada Health Act, and does, in fact, deliver some health care (to First Nations, Métis and Inuit people, veterans, etc.).

But more and more we’re hearing about the need for pan-Canadian solutions. The essential question being: what can multiple governments do, across Canada, that no one province can do effectively or sufficiently well on its own? Where does it make sense to look at truly pan-Canadian collaborative solutions to what has traditionally been viewed as a provincial matter?

This theme became louder and more dominant following a meeting of all provincial and territorial premiers in Victoria, BC at the beginning of this year, in large part as they reacted to the unilateral funding arrangements imposed by the federal government at the end of 2011.

Some may consider this a bold statement. But I believe, as a result of our successful transformation of the blood system, by virtue of our unique governance structure and funding, and our multi-provincial mandate, Canadian Blood Services has some capabilities and experience that can be leveraged to help inform change elsewhere in the health care system.

With the specific exception of Quebec, (where we do not operate), everything we do is pan-Canadian in nature. We operate a single integrated cost shared system for blood, plasma, stem cells and, more recently, for organ donation and transplantation (OTDT).

We are a living, breathing example of collectively achieving a better, more sustainable outcome for Canadians that would be much harder to achieve for any one region on its own.

Consider that any Canadian anywhere in the country gets equal access to blood of a standard quality and consistency, no matter where they live. What you get in Charlottetown, you get in Moose Jaw.

Consider our plasma protein product purchases, which are a highly successful example of "common bulk purchasing of pharmaceuticals" - something that has been on the radar screen of governments for years.

We operate and manage a $500 million drug formulary program on behalf of all the provinces and territories (excluding Quebec). We have sole responsibility for tendering and procuring over 35 biological drugs used to treat diseases such as hemophilia and immune disorders. By leveraging the buying power of all provinces and territories combined, we are able to achieve two critical benefits for Canadians: best pricing and enhanced security of supply.

Consider the novel and important source of stem cells for clinical transplant therapy that comes from umbilical cord blood. For that reason, we are in the process of establishing a national public umbilical cord blood bank. This urgently needed pan-Canadian program will leave a lasting legacy by helping to close the gap in access to health care for those patients waiting for a stem cell transplant.

And consider the organ and tissue donation and transplantation strategy laid out in Call to Action, an exhaustive evaluation of the challenges and opportunities in the OTDT environment in this country. It establishes priorities for a new, integrated, cost-shared interprovincial system and presents sweeping, targeted recommendations that will deliver measurable and tangible benefits to Canadians.

Canadian Blood Services is, by virtue of its physical presence, its successful transformation and its multi-jurisdictional governance, a great example of what pan-Canadian health care delivery can be. To be clear, this is not about Canadian Blood Services seeking to deliver health care services beyond those in which we are engaged, nor is it about our model being the only one worthy of exploration. But, through sharing our model of success, we do want to participate meaningfully in this ongoing debate on pan-Canadian health care delivery.

We would be proud to share with others what this means, and how our organization's learning can be leveraged for all Canadians. We look forward to being active in this debate going forward.

Tuesday, December 18, 2012

It is really hard if you don’t feel like you belong in this world

Rosie Dransfeld - Gemini award-winning Edmonton-based independent documentary filmmaker

In the past five years I’ve been working on various documentaries about Aboriginal people who live in urban settings. The first film, which won a Gemini in 2010, was Broke: a portrait of a pawnshop, the bank of the poor. Available on DVD at

This year I completed Who Cares, which features the dangerous and gritty world of street prostitution. The video is available at

At the end of next year, Antisocial Limited will be released. It is the story of an Aboriginal man, an ex-convict, who is struggling to start an all-Native construction company to beautify his down and out neighbourhood.

The levels of poverty, dysfunction and despair in the communities I visited are alarmingly high. On a daily basis they face racism and contempt. In the medical system they are often treated as second-class citizens, turned away too easily or have to endure longer waiting times. Distrust and alienation are consequential. “You cannot trust the white man.”

“It is really hard if you don’t feel like you belong in this world.”
This was the response from Shelly, a 40-year-old Aboriginal woman from Edmonton, when I asked her why she never tried to escape the vicious cycle of drug abuse and prostitution.

Shelly is one of the main characters in the documentary Who Cares. The film features the plight of street prostitutes. About 70 percent of the women in the sex trade are Aboriginal. They experience abuse from all sides: johns, drug dealers, pimps, and the other girls. The police harass and arrest them. The fines for soliciting and communicating for the purpose of prostitution are high. The only way for the women to pay them off so they don’t end up in jail is to go back on the streets to sell their bodies.  Every day is a struggle for survival. Impoverished and homeless, they are living in a war zone, with nowhere to go.

Most of the women and teenagers I interviewed during research and production of the documentary have been sexually abused as children. They often suffer from posttraumatic stress order, addictions, diabetes, STIs, TB and hepatitis, to name a few. 

Not only do these women feel ostracized within their communities but also by the medical system. I’ve heard many stories of doctors and nurses making racist comments, and morally condemning the women. Hence the levels of distrust and alienation towards the medical profession are very high.

Most likely the women will only see a doctor if they are gravely ill. Being homeless and disconnected from family and friends, it is impossible for them to follow up with treatment plans and make lifestyle changes. There are some efficient programs available to get women off the streets for the first 72 hours, but not much is there to guide them through the drastic adjustments they need to make to get out of their high-risk lifestyle. In addition, treatment for mental illnesses, e.g. FASD and posttraumatic stress disorder, is barely available and often hopelessly underfunded.

It seems that Western Medicine often fails to reach the Aboriginal patient. There is a total disconnect between the Western and the Native culture. Whereas Western Medicine focuses on directly related obvious causes of a disease, Native Medicine has a far more holistic approach. Despite the desperate damage to their communities and family bonds, most urban Aboriginals are still connected with their culture and the knowledge that you can only heal a body if you heal the soul.

If we want to reach out to the Aboriginal community, we need to respect their culture, treat them as responsible and knowledgeable human beings. We need to be humble, listen and take time.  Ideally we have to aim for synergy. We learn from them and they learn from us. Our Western medicine has a lot of flaws and in the long run I am convinced that we will benefit more from the Aboriginal community and its approach to healing than the other way around.

Friday, December 14, 2012

We need a new standard of care

Kandice Léonard, Regional Director, Aboriginal Health Programs 

The health disparities of First Nations, Inuit and Métis peoples are well known nationally, with disproportionate numbers of Aboriginal patients in our health care systems. This is even more so in Winnipeg.

Through much discussion with stakeholders, Winnipeg Health Region has recognized the need to adapt to our patient population, instead of asking our patients to adapt to us.

With many patients making their way to Winnipeg from rural and remote communities, away from their support systems and the comforts of home, receiving care in Winnipeg can be an incredibly disruptive and stressful experience. In order to facilitate the most successful experience for our Aboriginal patients, we need to provide programming and care that is relevant to them. This means having services tailored to the patient’s needs and a culturally educated and representative workforce delivering those services and programs.

As recognition of the value of culturally competent health services has grown, Aboriginal Health Programs in the Winnipeg Health Region has had an opportunity to expand and better accommodate the needs of our Aboriginal patients and our staff.

We offer First Nations language interpretation, spiritual and cultural care, planning for appropriate and safe discharges, advocacy and holistic healing. Our program also works to achieve a representative and culturally competent workforce by promoting health care careers to Aboriginal youth and adults, supporting our existing Aboriginal staff, and providing cultural education to health professionals. A better experience and better chance for health and healing can result from culturally safe care and environments in our facilities.

As care givers and employers, we need to provide as many tools as possible for a positive outcome. As a health region, we need to provide our staff with knowledge and opportunity to develop those tools.

Our program had a key role in the development of the Winnipeg Health Region’s Cultural Proficiency & Diversity Framework for Action, and we look forward to being a part of its implementation in the years to come.

Moving forward, it’s our goal to see regional implementation of culturally safe practices and to create a new standard of care. We’ve been working to expand our role by integrating our program throughout the region in the development of programs, services and policies in all program areas, particularly those that see high percentages of Aboriginal patients. With an integrated approach, we can change the way we provide care.

Kandice Léonard (
Regional Director, Aboriginal Health Programs – Winnipeg 


Moving Forward Together Aboriginal Health Programs Strategy

Aboriginal Health Programs – Winnipeg Regional Health Authority

Framework for Action: Cultural Proficiency & Diversity – Winnipeg Regional Health Authority

Cultural Education for Health Care Providers

Sacred Traditional Medicines in the Winnipeg Health Region – Article & Video

Breaking Down the Language Barrier

Hope & Healing –Wave Magazine

Medical Careers Exploration Program for Aboriginal Youth

Thursday, December 13, 2012

Cultural Competency – Part of creating a new space

Jeff Cyr, Executive Director, National Association of Friendship Centres

I was pleased to read in Empathy, dignity, and respect: Creating cultural safety for Aboriginal people in urban health care how far the dialogue on cultural competency has come.  There is no doubt that training health care personnel to become culturally competent is a priority, but re-focussing the discussion on understanding the legacy of colonization is a giant leap forward.  Together, creating a new space to critically assess the results of colonization, whether it is the health disparity and lack of cultural safety experienced by Aboriginal peoples or the systemic racism showcased by health care centres, ensures real on-the-ground changes are made.

Fostering the safety of urban Aboriginal peoples is the cornerstone of the work we do.  Realistically, it’s the majority of the work we do; in virtually every facet of urban Aboriginal life, safety and understanding of one’s culture is an afterthought.  An important example is the violence enacted against Aboriginal women in this country, where they are 3.5 times more likely than non-Aboriginal women to experience violence. Certainly, the over 600 missing and murdered Aboriginal women attests to the overrepresentation. In 2011/2012, the Friendship Centre Movement (inclusive of 8 Provincial/Territorial Associations, 117 Friendship Centres and one National office) offered 1,439 programs ranging from health (359 programs), youth (214 programs), family (164 programs), community (153 programs) and employment (122), to name a few.  Furthermore, 72% of the Friendship Centre Movement employees are women.

An important understanding was shared in the report, which states, people think that learning the facts about Aboriginal people is enough, but what’s really needed is a process of looking inside, self-reflection and unpacking their own attitudes, understanding, and actions about Aboriginal peoples. Meaningful, sustained change in beliefs and behaviours toward Aboriginal peoples will occur when one can challenge their own discomfort regarding the history of colonization, in what is now known as Canada.  Looking into the root causes of the vast disparities that exist between Aboriginal and non-Aboriginal people will create an appreciation of how best to rearticulate living together in a healthy way. This will ultimately change the racism, unfamiliarity and judgemental attitudes experienced not only in the health care setting but in society generally.

Programs like the Indigenous Cultural Competency Training Program are instrumental to enact meaningful change in our society.  Mandatory training in cultural competency for health care staff is a real solution to ending racism experienced by Aboriginal peoples accessing the health care system.  If cultural competency was mandatory for all post-secondary degrees, imagine the societal shift that would then occur.  With the great work shared as innovative practices, I am hopeful that one day community safety and health will be an everyday reality as opposed to the disparities currently experienced by our urban Aboriginal community members.

Wednesday, December 12, 2012

Navigating Cultural Safety in Newfoundland and Labrador

Katie Dicker, Senior Aboriginal Patient Navigator, St. John’s Native Friendship Centre

In 2002, our organization, along with the Division of Community Health within the Faculty of Medicine at Memorial University produced the Building Bridges Study, which was sponsored by the Strategic Social Plan.  The purpose was to look at ways to improve experiences for Aboriginal people in an urban health care setting. From the study came several outcomes, one being that there was a need to ensure the delivery of appropriate care to the province’s Aboriginal people, and another being that these individuals experience a wide range of difficulties in urban health care settings.

In 2005, the Cultural Diversity Working Group concluded that effective follow-up care for Aboriginal patients was a concern and that, according to the study, informants from Labrador reported that patients were returning home with incomplete information for follow-up care.  These two reports were the ground work that would become the basis of the Aboriginal Patient Navigator (APN) Program.

The APN Program offers support and assistance to Aboriginal patients/clients who are referred to St. John’s, NL for medical treatment.  Services and support include: navigation to appointments; arranging interpretative services in Innu Aimun and Inuktitut languages; assistance to access meals, transportation, accommodations and medical supplies; and discharge planning, liaising with internal and external agencies; as well as education and information sharing.

In our minds, the APN program is centred around enhancing cultural safety for patients. By ensuring that the physician understands the patient and by removing language barriers, an atmosphere of clear communication is created, which puts both the caregiver and individual patient at ease. Before the APN program existed, there were many situations when patients were left confused, with no understanding of the diagnosis, treatment plan or follow-up care. By providing patients with individuals who can communicate to them in terms they understand, this barrier is removed and patients are given tools to understand what the physician intended.

Through the APN program, we have learned that one of the most important factors in the longevity of programs like ours is having relevant data and showing its correlation to improved health outcomes for patients.  Since its inception, this program has assisted over 1500 patients and in the year after its pilot stage, we know that: 

* 85.7% of patients who participated in the evaluation survey felt the APN program minimized stress/anxiety;
* 64% believed that the program enhanced coordination of aftercare; and
* 57% believed the program raised awareness of cultural differences, practices and traditions.

At the end of the day, when you look at culturally based services that respond to community identified needs, it comes down to people, and ensuring that the people we provide services for get the most out of the time spent within the health care system.  It is said best by one of our previous clients in both his traditional languages and translated in English.

“Nakummek ilitsinut suliakagâtse tamâne. Ikajugatse
inûkatinet. Pitsiagusuagitse.”
“Thank you both for working here, because you are helping your people.  Keep doing the best you can.”

Tuesday, December 11, 2012

Indigenous Cultural Competency Training Program

By Leslie Varley, Director, Aboriginal Health Program, Provincial Health Services Authority

Recently, I had a conversation with a physician who works with international groups. He had high praise for the BC Provincial Health Services Authority’s Indigenous Cultural Competency (ICC) training and wished it could be made available at an international level. He spoke of groups unintentionally insulting and offending one another. “Some of the most advanced nations on earth just don’t get it,” he said, “They just don’t have self-reflection or awareness of how they are perceived by the indigenous peoples of the world.”

That got me wondering. Where do we as Canadians fit on the world spectrum of cultural competency? We share this land between ancient indigenous cultures and relatively recent settlers and immigrants.  ICC participants often tell us they regret some of the things they have said and done in ignorance of indigenous people, history, and culture, and they wish they had ICC training in elementary or high school.  If Canadians had knowledge of Indigenous people in the areas of pre-contact, the impacts of colonization and residential schools, and current restrictions of the Indian Act (the only race based act that we know of in the world), would the crippling stereotypes about Aboriginal people be reduced? What needs to happen for Canadians to change and improve the way they engage with indigenous issues? Is it having more information? Is it a deeper examination about our own biases and the relationship of these to our work? These are good questions.

A doctor recently asked, how do you talk to a colleague who you have just witnessed being culturally incompetent? How do you say what needs saying while maintaining your relationship with the colleague, but also pointing them to a course correction?

As Canadians, we are not accustomed to these difficult conversations of confronting cultural incompetency or racial micro aggressions. Treating indigenous people with repulsion, or outright contempt still happens because long held negative stereotypes are deeply embedded within Canadian culture. We want to confront the people demonstrating harmful behaviour, but we are often at a loss as to how to even start that conversation. We lack a common language around this issue. We are also concerned that what we say might threaten the relationship with our colleague. For others, we are afraid of repercussions, especially if the person who has been inappropriate is in a position of authority.

The Indigenous Cultural Competency Training program tackles these and other kinds of issues. We have health care professionals, students, education, justice, and social workers taking our training. We are making some gains in British Columbia. Over the last three years, the ICC program has trained about 10,000 people. This is a good start Canada, but we’ve got a lot more work to do.
ICC is an eight-hour accredited facilitated on line training program. The interactive training covers three key areas; knowledge, self-awareness, and skills development. Anyone can take the online ICC training. Check it out on our website at:

Making Canada’s health care system more culturally responsive to Aboriginal Peoples

Keith Neuman, Ph.D., Executive Director, the Environics Institute for Survey Research

The new report issued by the Health Council of Canada on cultural competency and cultural safety for Aboriginal People in urban health care is a welcome addition to what is hopefully a broader renaissance in how health care services are provided in this country.  This report presents the outcomes of regional roundtable sessions across the country focusing on an issue that lies at the nexus of two unfortunate trends in our country’s history:  i) the historic and still ongoing discrimination and stereotyping of Canada’s Aboriginal Peoples (which thankfully is diminishing); and ii) the increasing strain placed on the delivery of health care services due to rising costs and system demands.

The central premise addressed in these roundtables is clear. The current health care system is not designed to be sensitive to cultural differences that have a bearing on health outcomes, and has been especially inept in addressing the needs of the country’s Aboriginal Peoples because of systemic ignorance and discrimination. This problem is not limited to the health care system, but is arguably one area where the effects are most pronounced (along with education).

The report makes the telling point that establishing cultural competency is more than learning the facts but is developing a basis for empathy, to appreciate what it is like to be someone else. This was a major focus of the landmark Urban Aboriginal Peoples Study (UAPS), conducted by the Environics Institute for Survey Research in 2008-09 in 11 cities across the country (see  That study points to what is perhaps the greatest challenge for health care providers seeking to be more culturally competent in the services they deliver to Aboriginal people:  On the one hand to recognize that Aboriginal People share much in common with all Canadians (including providers (?)), having similar life experiences, values and aspirations (e.g., an education, a decent quality of life, a future for their children), while on the other hand to appreciate the distinct history and identity (as First Nations, Métis or Inuit) as they may bear on individuals’ health care needs.

This report provides an excellent overview of an impressive number of promising initiatives taking place across the country that are working towards developing and incorporating cultural competency and cultural safety into health care services for Aboriginal communities. There is surely much learning taking place as a result of this effort, and it is hoped that this knowledge is being shared with a broader range of health care providers, and will result in systemic improvements.  And perhaps there are lessons here about how better to serve the distinct health care needs of other ethnically and culturally diverse communities across the country.

Thursday, December 6, 2012

10 years since the Romanow Report – how to move forward

Gustavo completed his PhD from the Institute of Health Policy, Management and Evaluation at the University of Toronto in October 2012 and has provided part-time research and analytic expertise to the Health Council of Canada since September 2012.

Recently, I attended the CAHSPR forum, Ten years since the Romanow Report, a unique opportunity to discuss the advances in transforming health care in Canada, and a privilege due to the critical transcendence of this discussion at the current time. Not only has it been a decade since the Romanow Report, but we are also two years away from the conclusion of the 10-year period set in the 2004 First Ministers’ 10-Year Plan to Strengthen Health Care.

Overall, the forum featured thoughtful presentations with diverse visions on the challenges that our health care system is facing, and some ideas on areas where future action should focus. It particularly called my attention to the fact that the future directions look very similar to the ones identified 10 years ago by the Romanow Report. The advances that were highlighted as promising examples were mostly components of the reform that were supposed to be fully implemented and operative throughout Canada at this point, as committed to in the Accords. The lack of innovation and low levels of F/P/T collaboration were described as a constant throughout these years. We are about to reach the deadline, yet we are far from achieving the goals. An integrated, patient-centred, community embedded and adequately supported health care delivery system needs to be a priority in the near future. Missing in the presentations and discussion were the questions “why are some reforms failing?” and “what are we going to do to avoid having exactly the same discussion ten years hence?”

Fortunately, as a recent graduate from the PhD program at the Institute HPME at the University of Toronto, I was invited to attend the CAHSPR students’ discussion with the Honorable Roy Romanow after the general forum. I was impressed by the level of criticism that students - sometimes called “the new generation” - have about the accomplishments that “the old generation” has achieved in advancing towards an effective, efficient, integrated, and patient-centred Canadian health care system. Somehow, this part of the forum, far from the microphones and podiums, felt more authentic and constructive.

If we want to protect the principles of our health care system, we need to achieve permanent transformation, and be dynamic and adapt to changes in our society and the challenges it faces. We need more courage to go against the way things are when we know they are unproductive or wrong. We need dramatically more innovation to challenge the way we translate evidence into patient and community care, and in the way we translate those principles into a healthy population.

I encourage CAHSPR to continue to host these forums, and include new voices, and the Health Council of Canada to continue supporting them.

Gustavo Mery, MD, MBA, PhD

Tuesday, December 4, 2012

CPGs’ role in achieving a comprehensive approach to care

Susan Eng, VP, Advocacy, CARP

Clinical practice guidelines (CPGs) promote effective and consistent clinical care across all regions, and they can also have a vital role in ensuring quality care for complex cases. The Health Council of Canada has recognized that CPGs still need to expand to help those with multiple chronic diseases. Otherwise, in the current form, they are contributing to the fragmented nature of our system.

CARP’s One Patient model calls for an integrated care continuum, in which the health care system is comprehensive, easy to navigate, and patient-centric, taking into consideration the full spectrum of health needs as people age, particularly with multiple chronic conditions. Rather than responding exclusively to certain needs, One Patient takes into consideration people’s needs comprehensively, recognizing that those needs constantly change throughout people’s lives. CPGs are an opportunity to help attain this comprehensive approach to care, primarily through expanding the scope to include multiple chronic diseases, which will allow all patients to receive the appropriate care they need.

The health needs of our aging society demand a comprehensive approach. Studies and reports have shown that not only are there more people with chronic conditions but also more people who are dealing with more than one chronic disease. Patients want to know that the system will provide care for all their health needs, regardless of the number of chronic diseases they have.

Despite the importance of establishing greater patient engagement, national standards, and performance indicators, none of those efforts will help those with multiple chronic diseases unless the CPGs also address their needs. As a result, it is critically important that the next steps prioritize expanding the CPGs to be inclusive of multiple chronic diseases and making the system more comprehensive so that no one is left falling through the cracks.