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Evidence to Improve Care

Optimizing Chronic Disease Management in the Community (Outpatient) Setting


Ontario Health Technology Advisory Committee Recommendation

The Ontario Health Technology Advisory Committee takes this opportunity to re-emphasize that in managing patients with chronic disease (as in all other patient encounters) clinicians must recognize that unique patient factors—such as culture, language, education, income, and rurality—may influence both the clinical impact and patient acceptability of interventions such as dietary modification or depression/anxiety screening, as well as the locus of services (e.g., rural/urban, hospital/outpatient).

Read the full OHTAC Recommendation report



A chronic disease is any condition that someone lives with over the long term, such as heart disease, lung disease or diabetes. Chronic diseases are difficult for patients to manage and challenging for the health system. We need to find better ways for the health system to help support people with chronic diseases.


Health Quality Ontario Reviews Optimizing Chronic Disease Management in the Community (Outpatient) Setting

Effective management of chronic disease is better for patients, families, and the health system. This review looked at the following strategies: discharge planning; in-home care; continuity of care; advanced access scheduling; screening and management of depression; self-management support; specialized nursing practice; electronic tools for health information exchange; and health technologies. The goal was to determine which strategies produced the best outcomes for patients and were the most efficient for our health system.


Optimizing Chronic Disease Management in the Outpatient (Community) Setting: An Evidentiary Framework (PDF)
September 2013

Discharge Planning in Chronic Conditions: An Evidence-Based Analysis (PDF)
September 2013

In-Home Care for Optimizing Chronic Disease Management in the Community: An Evidence-Based Analysis (PDF)
September 2013

Continuity of Care: An Evidence-Based Analysis (PDF)
September 2013

Advanced (Open) Access Scheduling for Patients With Chronic Diseases: An Evidence-Based Analysis (PDF)
September 2013

Screening and Management of Depression for Adults With Chronic Diseases: An Evidence-Based Analysis (PDF)
September 2013

Self-Management Support Interventions for Persons With Chronic Diseases: An Evidence-Based Analysis (PDF)
September 2013

Specialized Nursing Practice for Chronic Disease Management in the Primary Care Setting: An Evidence-Based Analysis (PDF)
September 2013

Electronic Tools for Health Information Exchange: An Evidence-Based Analysis (PDF)
September 2013

Health Technologies for the Improvement of Chronic Disease Management: A Review of the Medical Advisory Secretariat Evidence-Based Analyses Between 2006 and 2011 (PDF)
September 2013

Optimizing Chronic Disease Management Mega-Analysis: Economic Evaluation (PDF)
September 2013

How Diet Modification Challenges Are Magnified in Vulnerable or Marginalized People With Diabetes and Heart Disease: A Systematic Review and Qualitative Meta-Synthesis (PDF)
September 2013

Chronic Disease Patients’ Experiences With Accessing Health Care in Rural and Remote Areas: A Systematic Review and Qualitative Meta-Synthesis (PDF)
September 2013

Patient Experiences of Depression and Anxiety With Chronic Disease: A Systematic Review and Qualitative Meta-Synthesis (PDF)
September 2013

Experiences of Patient-Centredness With Specialized Community-Based Care: A Systematic Review and Qualitative Meta-Synthesis (PDF)
September 2013


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The Ministry of Health and Long-Term Care endorses these recommendations.

The Ministry of Health and Long-Term Care has provided the following response: The Ministry, LHINs, hospitals, and primary care providers and other partners have implemented a number of initiatives to address these recommendations. For example, related to specialized nursing, the Ministry provides funding for Nurse Practitioners-Led Clinics and other interprofessional primary care models in communities across Ontario. Regarding health technologies, the Ministry funds the Ontario Telemedicine Network to facilitate provider-to-provider video consultations and eAssessments, as well as a telehomecare program for patients with chronic disease that has enrolled over 10,000 patients to date. The Ministry also funds home and community care services to help people of Ontario with functional limitations, disabilities, or health care needs (including those with chronic diseases) to live independently in the community. In 2015, the Ministry committed to expanding home and community care funding by 5% a year for three years. In 2016-17, this included a $100M increase in funding for home care for high needs clients, including patients with chronic diseases, and caregivers.




Health Technology Assessment at Health Quality Ontario

As part of our core function to promote health care supported by the best available evidence, we use established scientific methods to analyze the evidence for a wide range of health interventions, including diagnostic tests, medical devices, interventional and surgical procedures, health care programs and models of care. These analyses are informed by input from a range of individuals, including patients and clinical experts. The Ontario Health Technology Advisory Committee (OHTAC) — a committee of the Health Quality Ontario board of directors — reviews the evidence and makes recommendations about whether health care interventions should be publicly funded or not. Draft recommendations are posted on the Health Quality Ontario website for feedback. Final recommendations are approved by our board of directors and then shared with the Ministry of Health and Long-Term Care. For more detailed information, visit our Evidence to Improve Care pages.



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