Chronic Disease Management

Overview

Chronic conditions such as noncommunicable diseases (eg. diabetes, cardiovascular disease and chronic obstructive pulmonary disease) long term mental disorders and certain communicable diseases such as HIV/AIDS are the leading causes of death and disability in the world. The World Health Organization reports that currently chronic diseases are responsible for 60% of the global disease burden. In Canada, the current cost of illness, disability and death due to chronic disease is over $80 billion annually. In response to this growing burden many countries around the world are taking a great interest in improving the management of chronic conditions.

The Chronic Disease Management (CDM) Initiative with the Calgary Health Region began in 2002. The focus of the initiative is to develop a regional strategy for improving the management of chronic diseases across the continuum of care. The Region has adopted the Chronic Care Model developed by the MacColl Institute for Healthcare Innovation, Seattle as its framework for managing chronic conditions. This model has demonstrated that outcomes across a range of chronic diseases can be improved if a multifaceted approach is taken and attention is given to the community, health system, self-management support, delivery system design, decision support and clinical information systems. It provides a road map for improving the way organizations provide chronic illness care. Earlier this year CDM adopted British Columbia's Expanded Chronic Care Model.

The Region’s strategy for implementing the chronic care model is as follows:

To improve the management of people with chronic conditions in the primary care setting, the Calgary Health Region offers Chronic Disease Nursing support to Family Physicians within Primary Care Networks. The goal of the Chronic Disease Nurse is to assist people living with one or more chronic conditions to optimize their health and well-being. With the belief that the patient has a central role in managing their health, the nurse works with the individual to identify real and potential risks. The nurse supports people in health behaviour change, provides them with the knowledge, tools and skills to manage their disease(s) and provides case management, referrals to appropriate services and disease management according to clinical practice guidelines.
Increase the access of family physicians to specialist expertise and support by having regional staff from acute care specialty clinics see high risk/complex patients and have medical specialists provide continuing medical education (CMEs) and care algorithms for the care teams based on best practice
Implement an electronic Chronic Disease Management information system to allow all providers across the continuum of care to communicate with each other and monitor care. Embed alerts and reminders into the system so that they are available at point or care
Support patients through the ‘Living well with a Chronic Condition’ program -a community based exercise and education program run by the Region together with community facilities (such as the Talisman center and YMCAs). People with a range of chronic conditions exercise together in community facilities close to where they live and receive education about their specific health condition. The program is staffed with a multidisciplinary team of professionals including exercise specialists, physical therapists, dietitians and social workers
Provide personal support through the Stanford Chronic Disease self-management program. This program is lay led and suitable for people with a range of chronic conditions. The intent of the program is to help people make informed choices in their health behaviors and to develop positive lifestyle strategies to live as fully and productively as they can.




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CDM Home What is Chronic Disease Management Living Well Self Management Exercise Education Information for: Disease Management Nursing Diverse Populations New Initiatives Adolescents with a Chronic Condition Complex Chronic Clinic Prevention Provincial Dissemination FAQs Contact Us What's New? Canadian Chronic Care Network Program Information Days	Chronic Disease Management Overview Chronic conditions such as noncommunicable diseases (eg. diabetes, cardiovascular disease and chronic obstructive pulmonary disease) long term mental disorders and certain communicable diseases such as HIV/AIDS are the leading causes of death and disability in the world. The World Health Organization reports that currently chronic diseases are responsible for 60% of the global disease burden. In Canada, the current cost of illness, disability and death due to chronic disease is over $80 billion annually. In response to this growing burden many countries around the world are taking a great interest in improving the management of chronic conditions. The Chronic Disease Management (CDM) Initiative with the Calgary Health Region began in 2002. The focus of the initiative is to develop a regional strategy for improving the management of chronic diseases across the continuum of care. The Region has adopted the Chronic Care Model developed by the MacColl Institute for Healthcare Innovation, Seattle as its framework for managing chronic conditions. This model has demonstrated that outcomes across a range of chronic diseases can be improved if a multifaceted approach is taken and attention is given to the community, health system, self-management support, delivery system design, decision support and clinical information systems. It provides a road map for improving the way organizations provide chronic illness care. Earlier this year CDM adopted British Columbia's Expanded Chronic Care Model. The Region’s strategy for implementing the chronic care model is as follows: To improve the management of people with chronic conditions in the primary care setting, the Calgary Health Region offers Chronic Disease Nursing support to Family Physicians within Primary Care Networks. The goal of the Chronic Disease Nurse is to assist people living with one or more chronic conditions to optimize their health and well-being. With the belief that the patient has a central role in managing their health, the nurse works with the individual to identify real and potential risks. The nurse supports people in health behaviour change, provides them with the knowledge, tools and skills to manage their disease(s) and provides case management, referrals to appropriate services and disease management according to clinical practice guidelines. Increase the access of family physicians to specialist expertise and support by having regional staff from acute care specialty clinics see high risk/complex patients and have medical specialists provide continuing medical education (CMEs) and care algorithms for the care teams based on best practice Implement an electronic Chronic Disease Management information system to allow all providers across the continuum of care to communicate with each other and monitor care. Embed alerts and reminders into the system so that they are available at point or care Support patients through the ‘Living well with a Chronic Condition’ program -a community based exercise and education program run by the Region together with community facilities (such as the Talisman center and YMCAs). People with a range of chronic conditions exercise together in community facilities close to where they live and receive education about their specific health condition. The program is staffed with a multidisciplinary team of professionals including exercise specialists, physical therapists, dietitians and social workers Provide personal support through the Stanford Chronic Disease self-management program. This program is lay led and suitable for people with a range of chronic conditions. The intent of the program is to help people make informed choices in their health behaviors and to develop positive lifestyle strategies to live as fully and productively as they can.
	E-mail comments to Chronic Disease Management Webmaster. Page last updated on: February 05, 2010

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Chronic Disease Management

Overview