Making the Case for Change: Advancing the NWT Chronic Disease Management Strategy

Recommendations of the Report

The design and implementation of the improvement project (IP) pilots constitute significant steps towards an integrated, territory-wide CDM strategy. Project evaluation has, however, highlighted several factors related to communication, program monitoring and evaluation, and the availability of resources that must be addressed to ensure continued CDM improvement throughout NWT.

The Department has made seven over-arching recommendations intended in part to address these factors and sustain positive change that has been achieved through the CDM project:

Recommendation #1: Self-management support (SMS) should become standard practice for all primary care staff in NWT.

Recommendation #2: Adopt standardized policies and pathways for clinical referral and information sharing.

Recommendation #3: Support the use of integrated case management practices for patients with complex chronic care needs.

Recommendation #4: Integrate the use of evidence-based, standardized clinical practice guidelines for other chronic diseases.

Recommendation #5: Establish clear guidelines and pathways for patient consent and information sharing.

Recommendation #6: Establish standardized data collection and monitoring for all CDM initiatives.

Recommendation #7: Align future CDM work with the development of a territorial clinical information system.