Chronic Disease Management

Diverse Populations

An Innovative and Targeted Approach

Calgary is increasingly diverse in its population. 20% of Calgary’s total population was born outside of Canada. Canadians of South-East Asian, Hispanic, and African ethnicity, comprising 80% of Calgary’s minority populations, have much higher rates of chronic conditions, in particular diabetes and heart disease. Furthermore Aboriginal Canadians and homeless people have also been significantly and disproportionately affected by certain chronic illnesses, particularly diabetes, end stage renal disease, COPD, heart disease and mental illness. To compound the problem, these vulnerable populations experience considerable access barriers to health care utilization due to cultural, social and financial factors.

Since 2004, The Calgary Health Region has committed to providing the much needed Chronic Disease Management services for ethno cultural populations by formally establishing the Chronic Disease Management for Diverse Population Program within the mainstream CDM program. The Multicultural Chronic Disease Program’s framework is based on the principles and fundamental elements of the region’s Chronic Disease Management Model. It is modified to ensure cultural competency and is aligned with all three elements of the Living Well with a Chronic Condition program.

Click here to view a short video presentation.

Developing a socio-cultural aspect to the Regional CDM Program is essential to ensure that:

Chronic disease management programs are provided within a cultural and social context to meet the needs of Calgary’s culturally diverse ethnic populations

A variety of cultures do not experience barriers accessing chronic disease management programs and services.

This program is staffed by a multidisciplinary and multilingual team

It is offered in many different languages

It is delivered in accessible, community-based sites and utilizes numerous culturally-sensitive and credible educational tools which have been developed in this program. The content of the educational materials is developed in accordance with regional standards.

Sample Education Tools

Click here to view Post Gestational Diabetes Prevention (English)

Click here to view Post Gestational Diabetes Prevention (Punjabi)

Programs Available

Currently culturally-sensitive CDM programs that include nurse case management and the three components of the Living Well with a chronic condition program are available to Calgary’s two largest ethnic minority groups: Chinese and Indo-Asians

Indo-Asian CDM Program

The Indo-Asian component of CDM is offered in Punjabi, Hindi, Gujarati, Urdu and English languages. Disease specific education classes are offered. These classes focus on diabetes prevention, diabetes, hypertension, dyslipidemia management, lifestyle adaptation, chronic disease screening sessions and self-management workshops (Row Your Own Boat). These services are delivered in accessible community-based sites such as Dashmesh Cultural and Senior Centres, Ismaili mosques, and the Marlborough Community Centre.

Chinese CDM Program

The Chinese CDM program is offered in simplified and Traditional Chinese, Cantonese and Mandarin languages. The Disease specific education targeting diabetes prevention, diabetes, Hypertension, dyslipidemia management, lifestyle adaptation, COPD, chronic disease screening sessions and the self-management program (Row Your Own Boat) are delivered at the Calgary Chinese Elderly Citizen Association.

Care Pathway

Referrals come from physicians, other healthcare professionals and the patients themselves. Bookings are done through the reception at Chronic Disease Management headquarters, through Punjabi/Hindi/Gujarati and Chinese speaking clerical staff.

Program Expansion to other Diverse Populations

In 2005-06, an Environmental and Needs Assessment Study was completed to identify which ethnic groups /chronic conditions should be targeted next (Link to the Report). The results of this study identified the Vietnamese and Filipino populations as those who will benefit most from culturally-sensitive CDM programs.

Currently, strategic partnerships have been established with Vietnamese and Filipino organizations and stakeholders. The community leaders have expressed strong interest, support and willingness for the initiation of a culturally-sensitive CDM program in their communities. These organizations are committed to providing in-kind support, including space and volunteers for a multicultural CDM program.

Aboriginal CDM Program

Consistent with the region’s goal to improve the health status of the Aboriginal people, the Multicultural CDM program’s focus in the next five years will be on developing and implementing an effective and culturally appropriate chronic disease prevention and management strategy. Which will focus on enhancing the ability of the Aboriginal population to achieve optimal spiritual, mental, emotional, and physical health.

Currently strong partnerships have been formed with the Regional Aboriginal Health Program, Regional Aboriginal Community Health Council, Aboriginal Community Representatives, Elbow River Healing Lodge Team and other interested stakeholders. These groups will help to identify the needs and best strategies for an Aboriginal focused CDM program.

CDM Program for the Homeless Population

The development of a targeted CDM program for Calgary’s homeless people and shelter residents is currently in an exploratory and conceptual stage. The CDM for Diverse Population Program’s focus in the next five years will be identifying this vulnerable population’s short-term and long term service needs, developing strategic partnerships with multiple internal and external stakeholders serving the homeless (CUPS Community Health Centre, Alexander Health centre, primary medical care settings) and to develop and implement a safe and accessible CDM program for homeless people and shelter residents.




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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 Diverse Populations Programs Available \| Program Expansion An Innovative and Targeted Approach Calgary is increasingly diverse in its population. 20% of Calgary’s total population was born outside of Canada. Canadians of South-East Asian, Hispanic, and African ethnicity, comprising 80% of Calgary’s minority populations, have much higher rates of chronic conditions, in particular diabetes and heart disease. Furthermore Aboriginal Canadians and homeless people have also been significantly and disproportionately affected by certain chronic illnesses, particularly diabetes, end stage renal disease, COPD, heart disease and mental illness. To compound the problem, these vulnerable populations experience considerable access barriers to health care utilization due to cultural, social and financial factors. Since 2004, The Calgary Health Region has committed to providing the much needed Chronic Disease Management services for ethno cultural populations by formally establishing the Chronic Disease Management for Diverse Population Program within the mainstream CDM program. The Multicultural Chronic Disease Program’s framework is based on the principles and fundamental elements of the region’s Chronic Disease Management Model. It is modified to ensure cultural competency and is aligned with all three elements of the Living Well with a Chronic Condition program. Click here to view a short video presentation. Developing a socio-cultural aspect to the Regional CDM Program is essential to ensure that: Chronic disease management programs are provided within a cultural and social context to meet the needs of Calgary’s culturally diverse ethnic populations A variety of cultures do not experience barriers accessing chronic disease management programs and services. This program is staffed by a multidisciplinary and multilingual team It is offered in many different languages It is delivered in accessible, community-based sites and utilizes numerous culturally-sensitive and credible educational tools which have been developed in this program. The content of the educational materials is developed in accordance with regional standards. Sample Education Tools Click here to view Post Gestational Diabetes Prevention (English) Click here to view Post Gestational Diabetes Prevention (Punjabi) Programs Available Currently culturally-sensitive CDM programs that include nurse case management and the three components of the Living Well with a chronic condition program are available to Calgary’s two largest ethnic minority groups: Chinese and Indo-Asians Indo-Asian CDM Program The Indo-Asian component of CDM is offered in Punjabi, Hindi, Gujarati, Urdu and English languages. Disease specific education classes are offered. These classes focus on diabetes prevention, diabetes, hypertension, dyslipidemia management, lifestyle adaptation, chronic disease screening sessions and self-management workshops (Row Your Own Boat). These services are delivered in accessible community-based sites such as Dashmesh Cultural and Senior Centres, Ismaili mosques, and the Marlborough Community Centre. Chinese CDM Program The Chinese CDM program is offered in simplified and Traditional Chinese, Cantonese and Mandarin languages. The Disease specific education targeting diabetes prevention, diabetes, Hypertension, dyslipidemia management, lifestyle adaptation, COPD, chronic disease screening sessions and the self-management program (Row Your Own Boat) are delivered at the Calgary Chinese Elderly Citizen Association. Care Pathway Referrals come from physicians, other healthcare professionals and the patients themselves. Bookings are done through the reception at Chronic Disease Management headquarters, through Punjabi/Hindi/Gujarati and Chinese speaking clerical staff. Back to Top Program Expansion to other Diverse Populations In 2005-06, an Environmental and Needs Assessment Study was completed to identify which ethnic groups /chronic conditions should be targeted next (Link to the Report). The results of this study identified the Vietnamese and Filipino populations as those who will benefit most from culturally-sensitive CDM programs. Currently, strategic partnerships have been established with Vietnamese and Filipino organizations and stakeholders. The community leaders have expressed strong interest, support and willingness for the initiation of a culturally-sensitive CDM program in their communities. These organizations are committed to providing in-kind support, including space and volunteers for a multicultural CDM program. Aboriginal CDM Program Consistent with the region’s goal to improve the health status of the Aboriginal people, the Multicultural CDM program’s focus in the next five years will be on developing and implementing an effective and culturally appropriate chronic disease prevention and management strategy. Which will focus on enhancing the ability of the Aboriginal population to achieve optimal spiritual, mental, emotional, and physical health. Currently strong partnerships have been formed with the Regional Aboriginal Health Program, Regional Aboriginal Community Health Council, Aboriginal Community Representatives, Elbow River Healing Lodge Team and other interested stakeholders. These groups will help to identify the needs and best strategies for an Aboriginal focused CDM program. CDM Program for the Homeless Population The development of a targeted CDM program for Calgary’s homeless people and shelter residents is currently in an exploratory and conceptual stage. The CDM for Diverse Population Program’s focus in the next five years will be identifying this vulnerable population’s short-term and long term service needs, developing strategic partnerships with multiple internal and external stakeholders serving the homeless (CUPS Community Health Centre, Alexander Health centre, primary medical care settings) and to develop and implement a safe and accessible CDM program for homeless people and shelter residents. 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