Preventing and Managing Chronic Disease

Success Stories

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This small city has faced its challenges squarely and made some very big changes in the delivery of primary health care; changes that have resulted in better access for patients, improved continuity of care and more seamless patient flow between acute and primary health care services.   Read the full story here

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A patient’s first appointment here includes an intake assessment of the broader determinants of health so critical to effective chronic disease prevention and management including food security, social supports, employment security, housing and the like. The London team believes patients get lost because of a broken link between the health system and community resources.   Read the full story here

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It’s a structured, evidence-based, patient-centred program taught by trained volunteer lay leaders. The program runs 2.5 hours per week for six weeks and is designed to teach participants, and their care-givers or partners, the skills they need to manage the day-to-day challenges of living with a chronic health condition. The main goal is to improve the quality of their lives.   Read the full story here

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A simple protocol was implemented in the hospital: every person admitted – whether for a broken leg, heart palpitations or labour – is asked about his or her smoking status. If the person is a smoker, protocol requires that a nurse visit that patient during the hospital stay and offer assistance, including cessation medications.   Read the full story here

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They sought to create a patient-centred, one-stop-shopping approach to treat as many co-morbid conditions as possible. Specialists, GPs and other health care professionals would all be linked by electronic medical records.   Read the full story here

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Research is showing while there is a large investment up-front, overall, less time is spent per patient than in the traditional one-on-one model, and the outcomes are better. Readmissions for arthritis patients who attended the three-week TAP program dropped from 500 a year, when the program began, to just two.   Read the full story here

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Sault Ste. Marie

Since 1997, all the health care providers at Group Health Centre (GHC) access a single electronic medial record for each patient. Instead of relying on mailing or faxing charts and lab results, providers can make decisions based on a complete picture of a patient’s health. Patient care at all the chronic disease management programs at the Group Health Centre has improved significantly as a result.   Read the full story here

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