Full Report

Conclusion
The aim of chronic disease management is to improve the quality and outcomes
of patient care. Figure 3 * lists the key elements of CDM improvement and the
dimensions of quality associated with each element. The Department believes that
recommendations formulated on the basis of the pilot-project evaluations constitute
a comprehensive and sound approach to the improvement of CDM in NWT.
Figure 3
Key elements of CDM improvements
System Redesign
Decision support
To improve comprehensiveness
• Transdisciplinary teams
• Non-physician providers
To decrease practice variations and to improve conformity
to standards
• Clinical practice guidelines
To improve coordination of services and continuity of care
• Case management
• Clinical pathways & service agreements
To improve access
• Advanced access
• Max packing
• Telehealth
To provide incentives for access and efficiency
• Rostering
Support for self-management
To improve appropriateness, comprehensives, continuity
and outcomes
• Integrated into regular care
Clinical information systems
To improve continuity and comprehensives and
to enable evaluation
Leadership for improvement
To enable implementation
Community partnerships
To improve appropriateness and patient-centeredness
• Customer governance
To improve appropriateness and efficiency
• Working with community groups
To improve comprehensives and coordination
• Integration of health care & social services
*
Figure 3 was adapted from Kreindler (2009) and designed by lead faculty
Francois Champagne.
To improve outcomes
• Healthy public policies
23
Making the Case for Change