Chronic Disease Management

Primary Care Registered Nurses (PCRNs) use their knowledge and skills to address a variety of patient concerns, including:

• Lifestyle modification
• Chronic disease management
• Smoking cessation
• Health education

These preventive health services provide patients with the tools, education, and support needed to better understand and self-manage their chronic diseases.

How to refer

Enhanced and Comprehensive members can contact their Patient Care Coordinator through tasks or EMR messaging to set up patient appointments with a PCRN for chronic disease management.

Members can also consult with the PMH team to set goals for meeting clinical targets for certain types of patients. The PMH team can then actively call patients who have certain characteristics to book appointments with the PMH team or the physician.

Program details

PCRNs are trained in many areas related to chronic disease and have comprehensive education and/or certification in HealthChange Methodology, hypertension, heart health, diabetes, obesity and weight management, COPD, asthma, smoking cessation, various gastrointestinal issues, and many other conditions, including mental health concerns.

PCRNs work from home to support patients in a flexible booking structure where patients are seen any day their nurse is working. Appointments are primarily virtual, but in-person appointments are available depending on the patient’s needs and preference.