The Chronic Disease Management (CDM) Initiative
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by Jessie Venegas
18
Feb
2009
The focus of the initiative is to develop a regional strategy for improving the management of chronic diseases across the continuum of care. One of the strategies for implementing the chronic care model is to improve the management of people with chronic conditions in the primary care setting through Chronic Disease Nursing support 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, and provides case management, referrals to appropriate services and disease management according to clinical practice guidelines. It implements a number of other strategies as follows: • Increased access of specialized expertise for complex patients and continues training programs based on best practices. • Electronic CDM information system to facilitate communication between professionals, and embed alerts and reminders into the system so that they are available at point of care. • Patients support through the ‘Living well with a Chronic Condition’ program -a community based exercise and education program. • Personal support through the Stanford Chronic Disease self-management program
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18/02/2009
