Chronic Disease Management

Chronic Disease Nursing

Chronic Disease Management Nursing Support

Building on established partnerships with family physician in primary care within the Calgary Health Region, the role of the Chronic Disease Nurse (RN) is to support physicians in the primary care setting in the care of their patients with one or more of the identified chronic conditions.

Through collaborative care, the aim is to improve the management of people with chronic conditions. This is achieved by offering Chronic Disease Nursing support in the Family Physicians Practice.

The Chronic Disease Nurse assists people living with one or more chronic conditions to optimize their health and well-being. The patient has a central role in managing their health. The nurse works with the individual to identify real and potential risks at the bio-psycho-social-cultural-spiritual levels.

The nurse supports people in health behaviour change, provides them with the knowledge, tools and skills to manage their disease(s), coordinates referrals to appropriate services and provides case management/disease management according to clinical practice guidelines.

A Chronic Disease Nurse (RN) works with the family physician to monitor the health of patients with chronic conditions. The nurse has the ability to link two specialty services such as the diabetes, hypertension and cholesterol educators, dietitians, the Living Well program and the pain clinic.

Patient details are stored in an electronic information system that provides decision support which includes triggers for assessments, laboratory work and provides advice on clinical practice guidelines and treatment/referral recommendations.

This provides:

proactive planned care and communication within the interdisciplinary team

informed, empowered patients

coordinated care including

annual laboratory work, necessary annual assessments and ongoing monitoring by phone or mail

links to community programs and resources to help patients monitor and control their health

Algorithms

The Role of the Outpatient Dietician




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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 Chronic Disease Nursing Algorithms Chronic Disease Management Nursing Support Building on established partnerships with family physician in primary care within the Calgary Health Region, the role of the Chronic Disease Nurse (RN) is to support physicians in the primary care setting in the care of their patients with one or more of the identified chronic conditions. Through collaborative care, the aim is to improve the management of people with chronic conditions. This is achieved by offering Chronic Disease Nursing support in the Family Physicians Practice. The Chronic Disease Nurse assists people living with one or more chronic conditions to optimize their health and well-being. The patient has a central role in managing their health. The nurse works with the individual to identify real and potential risks at the bio-psycho-social-cultural-spiritual levels. The nurse supports people in health behaviour change, provides them with the knowledge, tools and skills to manage their disease(s), coordinates referrals to appropriate services and provides case management/disease management according to clinical practice guidelines. A Chronic Disease Nurse (RN) works with the family physician to monitor the health of patients with chronic conditions. The nurse has the ability to link two specialty services such as the diabetes, hypertension and cholesterol educators, dietitians, the Living Well program and the pain clinic. Patient details are stored in an electronic information system that provides decision support which includes triggers for assessments, laboratory work and provides advice on clinical practice guidelines and treatment/referral recommendations. This provides: proactive planned care and communication within the interdisciplinary team informed, empowered patients coordinated care including annual laboratory work, necessary annual assessments and ongoing monitoring by phone or mail links to community programs and resources to help patients monitor and control their health Algorithms Hypertension Weight Management Dyslipedemia Obesity The Role of the Outpatient Dietician
	E-mail comments to Chronic Disease Management Webmaster. Page last updated on: February 05, 2010

What's New?

Chronic Disease Management

Chronic Disease Nursing

Chronic Disease Management Nursing Support

Algorithms