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.

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

Physician, Nurse Practitioner, or NFHT Clinician referral.