Chronic Disease Management

Calgary Health Region, Home Care Program

This program is working on a Chronic Disease Management Initiative and has developed role algorithms and decision trees on areas such as diabetes, hypertension and COPD. These algorithms have been developed by the teams themselves as a team building exercise.

CDM Diabetes AlgorithimMay 31 04.pdf CDM Hypertension Algorithim May 31 2004.pdf Decision tree.pdf Physician billing code.pdf

Chronic Disease Management Toolkit

This is an expansion of the Ministry of Health Service's Secure Web Site for Practitioners where BC physicians can access a list of their patients with chronic conditions (such as congestive heart failure, diabetes, asthma and hypertension) and reports on the extent to which the care provided is consistent with BC Clinical Guidelines. http://www.healthservices.gov.bc.ca/phc/pdf/operationsmanual/S6_resources.pdf

Family Health Teams Guide to Chronic Disease Management and Prevention

This is a resource for those that have been approved to form a family health team in Ontario to guide them in creating localized plans for service. This guide provides information to plan and develop chronic disease management and prevention programs for patients and clients. http://www.health.gov.on.ca/transformation/fht/fht_guides.html

Group Health Centre, Sault Ste. Marie, Ontario

Formally a Health Service Organization (HSO) established since 1972, it has been cited by various commissions/task forces including Romanow and the Health Council. Serves a roster of over 60,000 patients. Services are offered by a diverse range of health professionals under a unique partnership governance model. Policies, procedures, and guidelines for chronic heart failure are presented.

GHC CHF Review Template.pdf GHC CHF admission procedureJune2005.pdf

Improving Chronic Illness Care

This includes clinical tools such as assessment of chronic illness care, tools for patients, collaborative training manuals, and more. www.improvingchroniccare.org/tools/index.html

Newfoundland Department of Health and Social Services

This province is moving forward quickly in interdisciplinary collaboration. Outlined below is the chronic disease management collaborative plan for 2004 to 2006. as well as guidelines and flow sheets for diabetes

CDM Collaboratives Nov 1 04 with change com.pdf Guidelines for Completion of the Diabetes.pdf Flow sheet june 2005.pdf

Provincial Stanford Chronic Disease Self-Management Leader Training Program

The purpose of this leadership training program is to: build resources & expertise help people in Alberta manage their life with chronic disease; increase health self-management skills and self-confidence; and enhance the skills required to problem solve and make decisions related to living a healthy life with a chronic condition.
http://www.health.gov.ab.ca/professionals/index.html#Professional

Saskatchewan Chronic Disease Management (CDM) Collaborative

Within the next year, Health Quality Council will be working with teams throughout the province to make significant improvements in managing coronary heart disease and diabetes in this province. A Collaborative is an improvement method that relies on the spread of existing knowledge about best practices to multiple settings to improve the quality of care and outcomes. It is based on the Institute for Healthcare Improvement from the United States.
http://www.hqc.sk.ca/portal.jsp?
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Wagner's Chronic Care Model

Dr Ed Wagner developed this approach to chronic care management. The Chronic Care Model identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The model can be applied to a variety of chronic illnesses, health care settings and target populations. http://www.improvingchroniccare.org/change/model/components.html

Western Health Information Collaborative

The Western Health Information Collaborative (WHIC) is a process initiated by the Western Premiers and Deputy Ministers of Health to explore collaborative opportunities with respect to health infostructure initiatives. The following are ongoing projects / initiatives at WHIC: Provider Registry; Client Registries; Pharmacy / PIN; Chronic Disease Management; Laboratory Information; Architecture; and Telehealth. http://www.whic.org/