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.
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.