Chronic Disease Management

In the Chronic Disease Management module, you will learn how to improve longitudinal care for patients living with chronic conditions using two powerful tools: patient registries and an automated recall system.
The two components complement each other to create improvements in care at the same time as streamlining administration. Patient registries track patient outcomes related to changes in care and help you monitor how treatment aligns with clinical guidelines. Automated patient recall ensures chronic patients are seen when they need to be and simplifies arrangements for lab tests, specialist referrals and patient education sessions. Together, these tools can increase your comfort in supporting chronic disease patients while also improving clinical outcomes and care processes.

You will learn how to:

• Shift chronic disease management from reactive, episodic care to a planned, proactive approach;
• Identify patients with chronic conditions;
• Create and manage a patient registry;
• Use flowsheets to track and manage patient care; 
• Implement an effective patient recall system;
• Support enhanced patient self-care, and
• Incorporate input and treatment from MOAs and other care team members

The Chronic Disease Management learning module was developed with family doctors in mind. As medical office assistants play a vital role in administrating patient records and scheduling appointments, they are also encouraged to participate.