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Apirl 27, 2006
The Chronic Disease Management Centre (CDMC) features a team
of primary and specialist physicians, along with a nurse practitioner,
treating individuals with chronic diseases. A unique aspect
of the Thunder Bay model will be to demonstrate linkages with
primary care.
Located in the medical centre adjacent to the hospital, it
will ensure physicians a link to the Hospital’s electronic
health record. This is a vital link for patients with a chronic
disease who may be more likely to seek hospital-based services.
The following focus areas have been identified for the CDM
Centre and may be designated as scheduled stand-alone clinics
or may be clustered into a general medicine clinic.
Diabetes • Hepatitis C and HIV • Narcotic Dependency
• Rheumatology Coagulation • Asthama/COPD •
Dermatology • Hypertension
The focus of care remains with the personal physician, supported
by an integrated practice team. Patients will require a referral
to a specific targeted clinic or the general internal medicine
clinic. Referrals may come from family physicians, the TBRHSC
emergency physicians or the TBRHSC Hospitalist program currently
serving orphaned inpatients. Should further diagnostics be
required, the CDM Centre physicians will order these.
An educational component in a disease management program,
preferably over a long period of time is an important factor
in disease management program’s effectiveness. An ambulatory
teaching unit for medical students and residents will be provided.
The nurse practitioner or other health care professionals
will provide targeted education for those populations served
by the unique programs of the CDM Centre. Where possible,
linkages with existing programs such as the Asthma Clinic,
Cardiac Rehabilitation Program or the Regional Stroke program
will be used. The Centre will ensure the appropriate follow-up
required.
The Centre will have access to the Hospital’s telehealth
resources. This will allow physicians and other members of
the multidisciplinary team to support individuals outside
of Thunder Bay in their own communities.
Goals and Objectives:
- Increase access to Chronic Disease Management services.
- Increase Health Promotion and Disease Prevention.
- Expand access 24/7 to Essential Medical Services.
- Create an Interdisciplinary Health Care Teams to provide
culturally sensitive Chronic Disease Management service. Other
members of the multidisciplinary team include a social worker
for the mental health clinic; diabetic educator for the diabetes
clinic; and a pharmacist for the coagulation clinic.
- Recognizing the unique cultural demographics of Northwestern
Ontario, a native liaison worker for ongoing consultative
purposes will be part of the team. This will provide the Centre
with a significant advantage in areas such as to translate
educational materials, design culturally appropriate self-management
tools, and create an inviting program for this population.
- Enhanced Learning Opportunities.
In keeping with the principles of primary health care reform,
it is anticipated that Family Practice Residents will rotate
through the Centre on a regular basis. The Northern Ontario
School of Medicine will require clinical opportunities for
medical students to acquire skills and knowledge. Teaching
opportunities will increase enhancing the recruitment and
retention of physicians.
Official Opening Ceremony
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