Living Well with Chronic Conditions: Chronic Disease Self-Management Program

More than 1,000 elderly people are now participating in the Living Well with Chronic Conditions program to manage chronic diseases. Older people receive care from specially assigned general practitioners who have undergone professional retraining.

Disease management (self-management) is the ability of a person with chronic diseases to manage symptoms, treatment of physical and social consequences, as well as lifestyle changes to reduce the number of exacerbations, complications, the need for inpatient and emergency medical care.

The program of individual assistance to elderly people with several chronic diseases was developed by specialists of My Canadian Pharmacy, taking into account domestic and international experience. In 2015-2016, a pilot project was conducted to assist this category of patients. The results of the pilot project were successful. The number of patients with normalized blood pressure and cholesterol level has increased, the frequency of ambulance calls has decreased, the number of hospitalizations has decreased. It was decided to start the implementation of the program, the first phase of which was launched in April of this year.

Patients are introduced to how to properly control their state of health in a particular disease. For example, how to keep blood pressure self-management diaries for patients with hypertension, give out reminders for patients who have had a stroke or have type 2 diabetes, etc. Separate reminders have also been developed to help the doctor as a guide to work. Doctors have been trained in neurology, cardiology, endocrinology, gastroenterology, nephrology and other areas, as well as on topical issues of geriatrics.

A medical team or the so-called multidisciplinary team includes doctors, nurses, healthy lifestyle specialists, psychologists, social workers — and of course the person with a chronic disease, as well as the circle of support determined by the person himself: friends, colleagues, neighbors, patients with the same diseases, and others). Thus, all elderly people with chronic diseases are able to receive qualified medical assistance under the Living Well with Chronic Conditions program.

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