Healthcare Quarterly

Healthcare Quarterly 13(3) May 2010 : 72-79.doi:10.12927/hcq.2010.21819
Chronic Disease Management

Advancing the Chronic Care Road Map: A Contemporary Overview

Sara Ahmed, Amede Gogovor, Mylene Kosseim, Lise Poissant, Richard Riopelle, Maureen Simmonds, Marilyn Krelenbaum and Terrence Montague


In an effort to assess and advance the community-based model of chronic care, we reviewed a contemporary spectrum of Canadian chronic disease management and prevention (CDMP) programs with a participatory audience of administrators, academics, professional and non-professional providers and patients. While many questions remain unanswered, several common characteristics of CDMP success were apparent. These included community-based partnerships with aligned goals; inter-professional and non-professional care, including patient self-management; measured and shared information on practices and outcomes; and visible leadership. Principal improvement opportunities identified were the enhanced engagement of all stakeholders; further efficacy evidence for team care; facile information systems, with clear rationales for data selection, access, communication and security; and increased education of, and resource support for, patients and caregivers. Two immediate actions were suggested. One was a broad and continuing communication plan highlighting CDMP issues and opportunities. The other was a standardized survey of team structures, interventions, measurements and communications in ongoing CDMP programs, with a causal analysis of their relation to outcomes. In the longer term, the key needs requiring action were more inter-professional education of health human resources and more practical information systems available to all stakeholders. Things can be better.



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