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Chronically Well!

Concerto Health Capsule
January 2013

Offering efficient health care services for patients with chronic diseases is a major challenge. But how should this category of services that uses the largest share of “heavy” resources in our health care systems be optimized? How should the services be coordinated around a family physician, and the interventions by each member of the interdisciplinary team be organized? In Chronically Well, the first issue in a series of health capsules, follow the highlights of the Concerto health model being implemented in Quebec.

Highlights: care pathways to simplify your life

Clinicians, patients, managers and decision-makers now have access to structured care pathways to follow up on people suffering from chronic diseases. They include functional logic diagrams for managing patients according to their pathologies, clinical protocols and collective prescriptions, a toolbox for patients and professionals, and an adapted lifestyle enhancement program.

Moreover, the pathways fit into the logical progress of the life of each patient. The table below presents a series of 15 pathways and 5 follow-up, screening and public health activities, according to their current availability. The choice is yours!

Individualized, computerized, deployed pathways Pathways designed to be computerized Pathways in the design process Pathways to be designed
Diabetes Chronic renal failure Mental health: Depression, anxiety disorders and adjustment disorders Arteriosclerotic heart disease
High blood pressure Heart failure   Oncology and palliative care
Dyslipidemia Attention deficit hyperactivity disorder: children, adolescents and adults   Chronic pain
COPD     Dementia and loss of autonomy
Screening, follow-up and public health activities
Neonatal follow-up
Pregnancy follow-up
Regular clinical assessment – Screening
Prevention – Health promotion

Results: efficiency gains achieved

In the next issue of this new Health Capsule, read about the service accessibility, continuity and quality indicators designed for the interdisciplinary follow-up of chronic disease patients in a family medicine group (FMG). See how implementing this vision of care organization can contribute to a significant reduction in the expenditure growth curve within your organization.

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