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.
This FLA OHT working group is embedding the chronic disease prevention and management approach into the Health Home framework, for individuals who are attached to a primary care team and those who are not yet attached.
Current Challenges
- The primary care crisis - with large numbers of individuals who are not attached to a primary care team - highlights a group who may not have access to health screening and 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.
- Hospital services are more focused on treatment than prevention due to high rates of admissions for acute care needs and complex cases.
- Preventative care efforts across the region are not well integrated - more collaboration needed.
- Community members are not aware of the many screening and preventive measures needed for achieving their best health.
What we are working towards
Design and plan 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
Preventive Care Model for All
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
World Health Organization, 1948
0 - 4 years
- Vaccines
- Psychomotor development
- Nutrition assessment
5 - 9 years
- Vaccines
- Nutrition assessment
- Dental hygiene
- Sexual education
10 - 19 years
- Vaccines
- Nutrition assessment
- Sexual health
- Healthy lifestyles
- Healthy relationships
- Substance abuse
20 - 59 years
- Metabolic syndrome screening
- Sexual health
- Healthy lifestyles
- Substance abuse
- Stress management
- Cancer screening
60+ years
- Visual & auditive screening
- Metabolic syndrome screening
- Healthy lifestyle
- Home care assessment
- Community Services
- Dental evaluation
Chronic Disease Prevention and Management - At a Glance
The Model
Embedding prevention and chronic disease management within primary care settings
The Chronic Disease Prevention and Management (CDPM) model was co-designed in collaboration with the Primary Care Network and Integrated Care Pathways groups.
This model is grounded in the Health Homes team-based approach, which addresses service gaps by centralizing resources, improving coordination among care teams, and streamlining referrals to specialized programs.
The Connection with Integrated Care Pathways
The Integrated Care Pathways (ICP) working group is establishing proactive management of chronic diseases - specifically heart failure and chronic obstructive pulmonary disease for now. Their work will expand to other conditions in the future.
While ICP delivers rapid-access clinics and emergency and hospital admission follow-up, evidence-based, standardized protocols, etc., CDPM drives early identification and proactive management in primary care and community settings.
The Partners
Primary Care/Community Care: Kingston Community Health Centres, Indigenous Interprofessional Primary Care Team, Ontario Health atHome
Hospital (Kingston Health Sciences Centre): SE Regional Cancer Program, Stroke Network, Regional Renal Services, Palliative Care
Public Health: South East Health Unit
FLA OHT: Project Lead and Project Manager, Digital Lead, Data Analyst
Community Council: Members
Who's involved?
Community members, primary and community care providers, municipalities, hospitals and specialists from across the region are working together. See The Partners above.
Community Council members may include people with lived experience, family, caregivers, Indigenous and Francophone representatives, 2SLGBTQ+ and others.