Full Report

Introduction
Forging an integrated strategy for chronic disease management
The Northwest Territories (NWT) Department of Health and Social Services
(the Department) launched the Chronic Disease Management (CDM) project in
September 2010 as part of an ongoing effort to reduce the risks and improve the
management of chronic disease in the NWT. The CDM project involves a partnership
with the Canadian Foundation for Healthcare Improvement (CFHI), a national
not-for-profit organization that collaborates with governments, policy-makers and
health system leaders to convert evidence and innovative practices into actionable
policies, programs, tools and leadership development.
Persistent and onerous
The World Health Organization defines
chronic diseases as being of long duration
and generally slow progression. The
ongoing and often complex management
of these diseases limits patients’ daily
activities and diminishes their quality
of life while imposing considerable
demands on their families, care providers,
communities – and the healthcare system.
CFHI facilitated a process (Figure 1) in which the
Department identified three over-arching project
objectives to be achieved over a two-year period:
1. Develop and implement diabetes, renal disease
and mental health improvement projects (IPs) *
that maximize the use of resources and provide
care based on evidence and informed practices.
2. Draw lessons from these projects to inform
development of an integrated CDM strategy.
3. Strengthen capacity and self-reliance for the use
of evidence to inform sustainable and efficient
health system decisions, processes and policy.
*
The IPs were initially called “tracer projects” in recognition of the tracer
methodology used in the planning process. The names were eventually
changed to “improvement projects” to clearly acknowledge the goal of
the CDM initiative.
5
Making the Case for Change