Projects - CDM

Chronic Disease Management

• Introduction
• Self Management Program
• Roll-Out
• Sign-Up

Introduction

The BCCFP was involved in teaching self management to physicians, their support staff and health authority representatives through the initial self management pilot program in 2004/2005.

Physicians who participated in the pilot program found it both professionally satisfying and easily integrated into their already busy offices.  Integration into, not work added onto existing practices, is the key to introducing this program into the clinical setting.

Based on the success of the pilot, a proposal to continue the self management program was presented and accepted by the government to allow the BCCFP to begin the program's spread and sustainability phase.

In 2006 the BCCFP trained over 60 physicians and their MOAs from all five health authorities.  The six month project for these cohorts will end Spring 2007.

Self Management Program

The self management program is directed at changing patient and physician behaviour with respect to treating and managing chronic disease - to change the focus from physician's agenda to the patient's.

It targets physician offices and their chronic disease patients, the very patients who are high utilizers of the health care system and who are particularly prone to accessing acute care facilities to manage their disease.  Motivating patients and their approach to their disease, facilitating behaviour change in conjunction with their physician, will benefit both patients and the health care system, improving health and reducing expensive emergency and hospital care.

Roll-Out

Training sessions for a limited number of physicians and their registered nurses and MOAs will take place in specified communities.  It is hoped that physicians who are trained will become trainers for other interested physicians.

The six month program will involve a four hour training session for physicians and an eight hour training session for registered nurses and MOAs.  Ongoing mentorship will be accomplished through  teleconferences and e-mail correspondence.  At the end of the six months a follow-up meeting will be held.

Travel costs and funding for physician and MOA time while at the initial training session and follow-up meeting will be provided.

Sign-Up

For more information or to sign-up, contact office@bccfp.bc.ca.