Chronic Disease Management

Chronic Disease Management (including Hypertension Program/COPD Program) – Team-based care for those living with heart or lung disease including Hypertension, Chronic Obstructive Pulmonary Disease or Congestive Heart Failure.

NFHT Chronic Disease Management Team will work with patients, caregivers, and their primary care providers to develop and implement an individualized and multi-level care plan that caters to the specific needs of the patient. Through thorough assessment, education, and ongoing support, NFHT patients living with a chronic illness, will better understand and self-manage their disease knowing when and where to access additional support when needed.

This program is for

Adults 18 years and older

living with a chronic or newly diagnosed disease (particularly HTN, COPD, CHF)
Note: Patients with Diabetes will be encouraged to work with the DEC for Diabetes Management, but can be supported by the NFHT Chronic Disease Management Team based on the benefit of the patient

Program Services

Patients will have an extensive in-person initial assessment (virtual as appropriate)
Relevant self-guided educational resources will be offered (online, print-out)
Ongoing education/support will be offered to the patient based on their identified areas of interest (individual, group)
Routine follow-up with a HCP based on intervals that both support the patients needs and align with evidence-based practice guidelines
Individual physiotherapy services including assessment and follow-up visits
Physiotherapist supervised group and circuit-based programs
Coordination with available community resources

Goals for participants

to demonstrate a better knowledge about their chronic disease and treatment, self-management and beneficial lifestyle changes
meaningful lifestyle change that will positively affect their chronic illness

Team

Doctor/Nurse Practitioner
a Registered Nurse, Registered Practical Nurse
Physiotherapist/CRE
Registered Dietitian
Mental Health Counsellor

How to access

Physician, Nurse Practitioner, or NFHT Clinician referral.

Any patient of the Northumberland Family Health Team with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) may self-refer: Click here to BOOK an appointment.

APPOINTMENT INFORMATION

Please arrive to appointments at least 5 minutes before scheduled appointment time to check in. Due to very high demand, we only allot the time needed per appointment.

Please try to give at least 24 hours notice of a cancellation as we always have a waiting list and aim to keep appointment slots filled.

COPD Information

Hypertension Information

Home Base Transition Care