Chronic disease management services assist adults with chronic conditions and difficulty managing their health or who want to know more about their condition.
What to expect
Your first visit may take up to one and a half hours. You will be seen by a chronic disease nurse who will work with you to:
- review your health concerns and chronic conditions
- review your medication and blood tests
- set small goals that you can achieve and help problem-solve issues that matter to you
- provide information on group health education
- link you to other members of the health team
- connect you to appropriate programs and services
- coordinate care with your doctor and other health care providers.
The chronic disease nurse will discuss the need for follow-up care.
Our chronic disease nurses can help clients living with chronic conditions to:
- increase understanding, skills, and confidence in managing your health condition(s), medication and role in chronic disease management.;
- provide self-management support so you can better advocate and manage your own health;
- loopback with your family physicians for collaborative patient care.
For primary care practitioners
Benefits in referring
- Communication with the chronic disease nurse about client care is billable (Bill G14077)
- Improved medical visits when patients have better understanding, skills, and confidence in managing their chronic disease(s)
- Enhanced coordination for patients with multiple care providers