Aging, Community and Health Research Group (ACHRU)

McMaster University

Funded by

Study 13

ACHRU Community Partnership Program for Diabetes Self-Management for Older Adults – Canada


In view of COVID-19, we are now offering the ACHRU-CPP Diabetes program virtually through videoconferencing and telephone. 

This program of research builds on our previous work to refine the Aging, Community and Health Research Unit (ACHRU) Community Partnership Program (ACHRU CPP) for a multi-site randomized controlled trial, to further evaluate its feasibility, acceptability, and outcomes. This new and innovative community-based model for diabetes care aims to improve diabetes self-management and the quality of care for a target population of community-dwelling older adults with diabetes and multiple chronic conditions (MCC). It is being tested in three provinces over four years with future plans to implement the CPP across Canada. A particular focus of this program of research was on assessing the effectiveness of the CPP in diverse groups, including high system users and those from different geographic and socio-economic backgrounds. 

This program of research consists of three interrelated studies which build on evidence of ACHRU-CPP feasibility and effectiveness from our prior work and is designed with scale-up in mind.

Study 1 – Population-Based Study 

Study 1 Co-Leads: Andrea Gruneir and Kathryn  Fisher

This population-based analysis aims to identify the socio-demographic, health and health service use characteristics associated with high use of the emergency department among our target population. The analysis uses administrative data from the provinces of Ontario and Alberta.
Study 1 results will provide a better understanding of the target population’s impact on resources, provincial and regional differences in impact, utilization patterns, and potential drivers of high emergency department use. This information in turn informs the recruitment of participants into the RCT (Study 2) as well as the analysis of the effects of the CPP and issues relating to the strategy for scaling up the intervention.

Study 2 – Clinical Trial Testing the Intervention
This cross-jurisdictional, multi-site pragmatic randomized controlled trial (RCT) will concurrently evaluate the implementation and effectiveness of the CPP in new settings and subgroups of the target population in Ontario, Quebec and Prince Edward Island. The goal is to demonstrate widespread effectiveness and ways to adapt the CPP for diverse population subgroups and primary and community care contexts.

Study 3 – Planning for Scale-up
This program of research was designed from the beginning with scale-up in mind, with the ultimate goal of developing a plan that provides a systematic and detailed strategy for large-scale implementation of the Community Partnership Program in each study province.
The plan will map the social, political and organizational environments in which the ACHRU-CPP can be scaled-up in each province. Ultimately, the scale-up plan will serve as a guidance document. Decisions regarding locations and organizations selected for early ACHRU-CPP adoption rest with policy- and decision-makers and organizations implementing the program. The scale-up plan will provide information to make initial scale-up decisions, tools to evaluate progress as scaling-up occurs, and activities that need to be undertaken to enhance and sustain future scale-up. The plan is the foundation to begin the scale-up process, recognizing that strategic planning will adjust as factors affecting scale-up are identified, implementation experience accumulates across settings and populations, and as health and social systems/structures change.


Canadian Institutes of Health Research SPOR Primary and Integrated Health Care Innovations Network: Programmatic Grants (Funding Reference Number: KPG-156883)
Diabetes Action Canada
McMaster Institute for Research on Aging
Scarborough Health Network
Scarborough Health Network Foundation
McMaster University School of Nursing
Fonds de recherche du Québec – Santé (FRQS)

Collaborator: Catharine Whiteside, Executive Director, Diabetes Action Canada

Study Partners

OntarioSt. Michael's Hospital, Greater Toronto YMCAScarborough Health Network, Carefirst

Quebec: Groupe de Médecine de Famille Universitaire (GMF-U) Saint-Charles-Borromée, Fédération de l'âge d'or du Québec (FADOQ) – Lanaudière, Groupe de Médecine de Famille Universitaire (GMF-U) Saint-François d’Assise, Fédération régionale des OBNL d'Habitation de Québec, Chaudière-Appalaches (FROHQC)

Prince Edward Island: Sherwood Business Centre and Four NeighborhoodsUniversity of Prince Edward Island’s Health Centred Research ClinicHarbourside ClinicSt. Eleanor’s Community Centre

Knowledge User Partners:

Patrick Dicerni, Principal Knowledge User
Bill Johnson, Principal Knowledge User Patient
Phil Graham, Knowledge User

Related ACHRU News Story: Innovative Community-Based Model for Diabetes Care Moves Forward


Issue 1-June 2019

Issue 2-December 2019

Issue 3-April 2021

Issue 3 Part 2-May 2021



  • Jenny Ploeg
    Professor Emeritus
    McMaster University School of Nursing
    Department of Health, Aging and Society
  • Maureen Markle-Reid
    Professor and Canada Research Chair in Person Centred Interventions for Older Adults with Multimorbidity and their Caregivers
    McMaster University School of Nursing
    Scientific Co-Lead, MIRA Collaborative for Health and Aging (OSSU SPOR Research Centre)
  • Andrea Gruneir
  • France Légaré
  • William J. Montelpare
  • Kathryn Fisher
  • Rebecca Ganann
  • Lynn Mansell
  • Frank Tang
  • Ross Upshur
  • Ali Ben Charif
  • Johanne Blais
  • Dean Eurich
  • Amiram Gafni
  • Gary F. Lewis
  • Lori MacCallum
  • Janet MacIntyre
  • Jean-Sébastien Paquette
  • Marie-Ève Poitras
  • Janet Pritchard
  • Angela Riveroll
  • Cheryl A. Sadowski
  • Diana Sherifali
  • Lehana Thabane
  • Tyler Williamson
  • Melissa Northwood
  • Tracey Chambers
  • Robyn Connors
  • Coralie Assy

Publications and Activities relating to this study:

Our Work is Featured in the Latest Diabetes Action Canada Podcast

The latest episode of Diabetes Action Canada’s Actions on Diabetes podcast features our Co-Scientific Director Dr. Rebecca Ganann and our community research partner Ron Beleno, discussing their research about diabetes in older adults.

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Our Diabetes Community Partnership Program (CPP) is highlighted on the Diabetes Action Canada Website

We are pleased to have our Community Partnership Program for Diabetes Self-Management for Older Adults – Canada featured in a story on the Diabetes Action Canada website.

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Promoting Independence in Older Canadians with Diabetes

ACHRU is featured as one of Diabetes Action Canada’s research programs on their new bilingual website.

Read More