Chronic Disease Management

This learning module provides GPs with new approaches for improving management of patients with chronic disease. Physicians and their MOAs learn how to use patient registries and an automated patient recall system, which can significantly improve patient care by ensuring that patients with chronic disease are seen when they need to be seen. Planned recall is also helpful for arranging lab tests, referrals to specialists and patient education sessions.

Physicians engaging in CDM qualify for incentive fees.  They will also be more comfortable managing patients with chronic conditions, while their patients benefit from more proactive, guideline-based care. Patient registries provide feedback on patient outcomes related to changes in care, and helps physicians monitor how well their practice is meeting clinical guidelines.

The CDM module includes training sessions in two key areas: developing patient registries and implementing planned recall.

Learning outcomesPatient Registries After completing the activities for developing patient registries, GPs and their MOAs will be able to:

  • identify patients with chronic conditions
  • create a patient registry 
  • use flowsheets to track and manage patient care  
  • assess whether the patient registry is improving care management and make necessary adjustments as needed

Planned RecallAfter completing the activities for implementing planned recall, GPs and their MOAs will be able to:

  • implement an effective patient recall system
  • generate reports from the CDM Toolkit
  • assess how planned recall is improving management of patient care

 

Benefits

Patient Registries
 For Patients  For Physicians
  • enables patients to manage their care  
  • increases patient satisfaction
  • increases likelihood of follow-up care for patients
  • prevents complications through early treatment.

  • improves clinical outcomes and care processes for all conditions
  • streamlines administration, helps physicians feel more organized
  • enables medical team to identify problems and explore other treatment approaches
  • allows input and treatment by MOAs and other care team members.

 

 

Planned Recall
 For Patients For Physicians
  • increases likelihood of follow-up for patients who need it
  • targets hard-to-reach patients
  • prevents complications through proactive treatment 
  • helps patients self-manage their care
  • increases patient satisfaction
  • helps physicians target care to meet patient needs
  • improves clinical outcomes and care processes 
  • facilitates other practice improvements, such as group visits and patient self-management 
  • improves professional satisfaction
  • facilitates clinical research


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