NWT chronic disease management collaboration results in better care, roadmap for system change

by admin admin | Sep 26, 2013


Yellowknife, Canada - Sept. 26, 2013 – A new report released by the Northwest Territories Department of Health and Social Services (DHSS) in partnership with the Canadian Foundation for Healthcare Improvement  (CFHI) provides a detailed strategy for reducing the rate and impact of chronic disease in the region. It highlights the successes, challenges and lessons learned through three improvement projects focused on renal disease, mental health and diabetes.

DHSS and CFHI have been collaborating since December 2010 to develop a territory-wide chronic disease management (CDM) strategy to improve health services for people living with chronic diseases. The report, Making the Case for Change: Advancing the NWT Chronic Disease Management Strategy, outlines notable improvements in patient care, including earlier identification and diagnosis of chronic kidney disease (CKD), greater standardization of care, more timely and appropriate referrals and better engagement and management of patients, which have all clearly demonstrated how NWT can provide better care to patients with chronic disease.

In addition to improving the quality of care, the collaboration also highlights areas of potential cost savings. For example, the early identification and treatment of CKD holds the potential to generate significant savings from reduced spending on lab tests, physician time, medications, dialysis and, eventually, kidney transplants.

“Our government is committed to improving the health of Canadians,” said Canada’s Minister of Health, Rona Ambrose. “This collaborative approach to finding innovative solutions is a great example of how governments and health system leaders can work together to improve the health system for all Canadians.

The improvement projects have also introduced a range of practical and customized tools such as renal care clinical practice guidelines (CPGs), a renal consultation form, diabetes self-management training packages, a centralized renal patient database and referral intake, and standardized referral and information sharing pathways for mental health.

Improvement projects were led by interdisciplinary, cross-regional improvement teams of healthcare executives, policy-makers and clinical leaders from DHSS and eight regional health authorities. In addition to improving patient care and developing improvement tools, the CDM collaboration also strengthened local capacity in evaluation, change management and performance management by training approximately 80 DHSS staff and involving another 190 in the process.

The Northwest Territories is committed at all levels to creating systems and environments that improve health and health services. Our work with CFHI and the report recommendations go a long way toward integrating best practices in the design of health services through effective partnerships with communities,” said Tom Beaulieu, NWT’s Minister of Health and Social Services.

The report recommends several strategies for driving further improvement in the NWT: 



  1. Self-management support becomes standard practice for all primary care staff.
  2. Adopt standardized policies and pathways for clinical referral and information sharing.
  3. Support the use of integrated case management practices for patients with complex chronic care needs.
  4. Integrate the use of evidence-based, standardized clinical practice guidelines for other chronic diseases.
  5. Establish clear guidelines and pathways for patient consent and information sharing.
  6. Establish standardized data collection and monitoring for all CDM initiatives.
  7. Align future CDM work with the development of a territorial clinical information system.

 “CFHI has appreciated the opportunity to support dedicated staff throughout the NWT as they applied evidence, combined with local expertise, to improve the health of those living with chronic disease,” said Stephen Samis, CFHI’s Vice-President, Programs. “Through initiatives like the NWT Collaboration, CFHI is accelerating healthcare improvement in Canada.”

In addition to federal support for the Canadian Foundation for Healthcare Improvement, funding for this report and the three improvement projects was provided in part by the Government of Canada's Territorial Health System Sustainability Initiative (THSSI), Health Canada's Aboriginal Diabetes Initiative, and the Public Health Agency of Canada's Canadian Diabetes Strategy.

For more information:


Paulette Roberge
Senior Communications Specialist
Canadian Foundation for Healthcare Improvement
W: (613) 728-2238 ext. 288
C: (613) 790-1070
E: paulette.roberge@cfhi-fcass.ca 

Damien Healy
Manager, Planning and Communications
Department of Health and Social Services Northwest Territories
W: (867) 920-8927
E: damien_healy@gov.nt.ca