Full Report

Executive Summary
The Chronic Disease Management (CDM) project was launched in September 2010 as
a partnership between the NWT Department of Health and Social Services (DHSS) and
the Canadian Foundation for Healthcare Improvement (CFHI), a national not-for-profit
organization. An integral part of the Department’s ongoing efforts to reduce the risk and
improve the management of chronic disease, the CDM project pursued three objectives:
• Develop pilot improvement projects (IPs) that maximize the use of resources
and provide care based on evidence and informed practices.
• Apply lessons from these projects in the development of an integrated CDM strategy.
• Strengthen capacity and self-reliance in the use of evidence to inform sustainable
and efficient health system decisions, processes and policy.
Targeted pilot projects
The IPs addressed three chronic disease areas:
diabetes, renal disease and mental health. The
diabetes IP team focused on building the capacity
of primary care teams to provide self-management
support (SMS) to people with type 2 diabetes in
Behchoko, Norman Wells and Yellowknife. To support
this goal, the IP team created a self-management
training package, delivered SMS training to primary
care service teams, and implemented SMS activities
as part of routine care in each pilot site.
The renal disease IP team focused on integrating the
provision, and increasing the consistency of renal
care across the Territory. Yellowknife Health and Social
Services Authority (YHSSA) and Hay River Health and
Social Services Authority (HRHSSA) supported the
project through the piloting of a centralized renal
patient database while Stanton Territorial Health
Authority (STHA) supported the project through the
use of their central referral intake. The IP team set out
to standardize the definition and process for primary
care decision support of early stage renal disease
detection and management.
The mental health IP team focused on standardizing
referral practices and the sharing of mental health
information between the communities of Fort Good
Hope and Fort Simpson and the psychiatry unit and
emergency department at STHA and outpatient psychiatry
at YHSSA. During the pilot, the team developed
standardized referral and information sharing pathways,
trained care providers on use of the new pathways, and
implemented the pathways in the pilot communities.
Marked improvements
In less than three years, the CDM project has
strengthened local capacity in evaluation, change
management and performance management. It has
enhanced leadership and engagement by training
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Making the Case for Change