Chronic Disease Management Strategy

Integrated, culturally appropriate, territory-wide chronic disease management

Walking in snowy NorthSince December 2010, the Canadian Foundation for Healthcare Improvement (CFHI) has been collaborating with the Northwest Territories (NWT) Department of Health and Social Services (DHSS) towards the development of a Chronic Disease Management (CDM) Strategy for the Territory.

Through the use of CFHI’s approach, the DHSS identified three over-arching objectives:

  1. Develop and implement diabetes, renal disease and mental health improvement projects that maximize the use of resources and provide care based on evidence and informed practices. 
  2. Draw lessons from these projects to inform development of an integrated CDM strategy. 
  3. Strengthen capacity and self-reliance for the use of evidence to inform sustainable and efficient health system decisions, processes and policy.

The CDM Collaboration was carried out over two phases:

  • Phase I – assessment and design of improvement projects for patients with diabetes, renal disease and mental health, developed to use resources and deliver services based on best evidence and practices.
  • Phase II – implementation and evaluation of the improvement projects across select pilot sites throughout the territory. Improvement projects are designed to test improvement on a small scale and inform the DHSS as they develop, implement and sustain an integrated chronic disease management strategy.

Senior woman smiles at cameraMaking the Case for Change – CFHI led an evaluation of the improvement projects in spring 2013. The report Making the Case for Change: Advancing the NWT chronic disease management strategy highlights outcomes, achievements, lessons learned and options for sustainability and spread of the most effective elements of improvement projects. Drawing on these findings, the report presents recommendations towards an action plan in the development of an integrated chronic disease management strategy based on best practices and sound evidence.

Guided by a steering committee and expert CFHI faculty the CDM collaboration has strengthened local capacity in evaluation, change management and performance management. It has enhanced leadership and engagement by training approximately 80 staff and involving another 190 in the improvement projects. It has introduced a range of practical, customized tools and processes to health care practitioners. Most importantly, it has demonstrated how we here in NWT can provide better care to patients with chronic disease.

Learn more

Collaboration partners have produced a wealth of communications and educational resources that provide greater detail on this collaboration, including:

For more information contact:




NWT Steering Committee

Donna Allen – Director, Territorial Health Services, DHSS
Kay Lewis – Chief Executive Officer, Stanton Territorial Health Authority, NWT
Andy Langford – Director, Community Wellness and Social Services, DHSS
Kimberly Riles – Manager, Primary community and Acute Care Services, DHSS
Laura Seddon – Director, Population Health, DHSS
Kami Kandola – Deputy Chief Public Health Officer, DHSS
Jim Corkal – Medical Director, Stanton Territorial Health Authority, NWT
Les Harrison – CEO and Director, Social Programs, YHSSA
Vickie Lafferty – Manager, Continuing Care and Health Systems Planning, DHSS
Ruchie Lamba – Senior Project Manager, DHSS (ex-officio)
Melanie Morse – Project Coordinator, CDMP, DHSS (ex-officio)
CFHI – (ex-officio)