Feature: Managing chronic disease in your patient population

As a physician, you know the impact chronic diseases have on patients — but the numbers can still be alarming.

The data shows:

• 44 per cent of Canadian adults over the age of 20 have at least one chronic health concern
• 58 per cent of deaths in Alberta in 2001-09 were the result of chronic disease

Our Patient Medical Home (PMH) team members support Enhanced and Comprehensive members in addressing this widespread concern through patient outreach, screening initiatives, patient care, and education services.

Each PMH team member has a vital role in chronic disease prevention and education:

• Primary Care Registered Nurses (PCRNs): Meet with patients to provide preventative health services, education, and support patient self-management for hypertension, heart health, diabetes, obesity, pregnancy, IBS support, tobacco cessation, and more. They provide diabetes foot assessments, healthy lifestyle and behaviour change support, ongoing patient monitoring, and other services.
• Patient Medical Home Coordinators (PMHCs): Health Information Coordinators (HICs) and Patient Care Coordinators (PCCs) use EMR data to identify, facilitate, and support chronic disease screening projects.

Proactive outreach, screening, and management of chronic diseases are critical to the long-term well-being of patient populations.

Additional information regarding our chronic disease management program, including referral directions, can be found in our Programs & Services Guide and on our chronic disease management web page.