Chronic disease prevention and management (CDPM) is an approach to health care that focuses on helping individuals stay healthy and maintain independence through prevention, early detection and management of chronic conditions. Chronic disease is any condition that requires ongoing management, cannot be prevented by vaccines or cured by medicines. Examples are diabetes, heart or lung disease and dementia.
Integrated Care Pathways are roadmaps that organize a person living with chronic conditions journey through the health-care system. Instead of treating health care as a series of disconnected visits – where a patient has to manage their own transitions between a family doctor, a hospital specialty and home support – an integrated care pathway connects all of these providers into one coordinated care team.
Current Challenges
- Primary care appointments are often short and have limited time to spend with each person, yet diagnosing and managing chronic conditions requires ongoing time and attention.
- Barriers such as limited transportation and difficulty accessing resources make it hard for people to get the care they need and therefore chronic diseases can potentially worsen.
- People who are admitted to a hospital for COPD and CHF are more likely to be readmitted.
- A lot of people are still not attached to a family physician or nurse practitioner, leaving them without regular access to routine health screenings and preventative disease management.
- Rates of risk factors for vascular disease, such as obesity, hypertension and smoking, are higher across our region than for the rest of Ontario.
- Many community members are not aware of the many screening and preventive measures needed for achieving their best health.
What we are working towards
Implement a local model that is:
- Anchored within primary care and community settings
- Evidence-based, equity-informed, and data-driven
- Integrated with care pathways for CHF, COPD, diabetes, mental health & addictions
- Partnered with Indigenous and underserved communities
Establish early detection and intervention by:
- Outreach through community events and mobile clinics
- Connections to established pathways
- Strengthening attachment to primary care providers and team-based care
Improve outcomes and system impact by:
- Embedding a preventive care model and chronic disease management in Health Homes, including care for equity-deserving populations
- Increasing primary care attachment, especially for unattached patients
- Reducing hospitalizations and emergency room visits
Chronic Disease Prevention and Management - Projects
Regional Lung Health Program
FLA OHT partner Kingston Community Health Centres offers several FREE services for people across the FLA region:
- COPD education & self-management
- STOP-smoking program
- Diagnostic assessment, including spirometry
- Modified pulmonary rehabilitation program
These services are offered at KCHC sites in Kingston and Napanee. People can self-refer for some services; primary care provider referrals and medical clearance are required for some services. Learn more on the KCHC webpage.
Cancer Screening
The CDPM Working Group was established in fall of 2025. It is currently identifying opportunities to expand awareness and access to screening for breast, cervical, lung, and colon cancer.
Activities will include public awareness campaigns for existing screening programs, and targeted mobile screening and outreach in communities with low screening rates.
For more information, download our Cancer screening guide.
Questions about cancer screening initiatives? Email us at: info@flaoht.ca
Best Care Program Pilot
The FLA OHT partnered with Best Care, a not-for-profit organization that collaborates with the health-care teams. Since 2024, two Case Managers (a Registered Nurse or Registered Respiratory Therapist) with expertise in cardiac and respiratory care have been working within 19 Health Homes in the region. This program involves:
- screening people who would benefit from diagnostic tests
- supporting with care planning, patient education, and medication management
- referring for specialized care, allied health, community support and more
Questions? Contact Dendra Hillier at dendra.hillier@kingstonhsc.ca
Resources for Providers
Integrated Care Pathways (ICP) provide treatment algorithms, referral information and much more. Click below to download or visit these resources:
- Map: Integrated continuum of care for chronic conditions
- KHSC Care Pathways: for COPD, heart failure and other conditions
- Presentation: Palliative care needs in heart failure
ACCREDITED LEARNING ACTIVITY: ICP Collaborative Session (RCPSC):
Questions? Contact Dendra Hillier: dendra.hillier@kingstonhsc.ca
Resources for Community Members
Helpful information is available by visiting these sites or downloading these guides:
COMING SOON:
My Wellness Guide is a practical resource is designed to help you better understand and navigate your health and well-being. Within this pocket-sized booklet you will find:
- Important numbers and links for support
- How to find a primary care provider
- A place for your health "snapshot" of your medical history, allergies, medications, etc.
- Vaccine guides
- Tips for prevention including cancer screening and an active healthy lifestyle
You can use this guide to take a more active role in your health and wellness, identify important care and screening opportunities, and connect with the supports available to you.
Who's involved?
FLA OHT partners are working together to develop Integrated Care Pathways to help manage chronic diseases in the community, starting with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Our partners have also come together to create a CDPM Working Group, which aims to embed the chronic disease prevention and management approach into the Health Home framework.
Community members, primary and community care providers, municipalities, hospitals and specialists from across the region are working together.
Community Council members may include people with lived experience, family, caregivers, Indigenous and Francophone representatives, 2SLGBTQ+ and others.