From: Disease management projects and the Chronic Care Model in action: baseline qualitative research
Project site | Chronic illness | Team | Program |
---|---|---|---|
Clinic for eating disorders and addictions | Eating disorders | On-site leadership team 1 project leader (MD) 1 project manager (Social worker) 4 mini-project leaders | 4 fold project to reduce barriers to access to support and treatment for eating disorders |
GP practice group | Cardiovascular risk (CVR) management | On-site leadership team 2 project leaders (MDs) 1 project manager (RN) | Manage CVR through patient portals, patient care plans, and interdisciplinary care teams |
GP practice group | Diabetes | Consultant leader 1 project leader (Health care consultant) | Train clinicians and other health care givers to manage diabetes in first line care |
GP practice group | Chronic obstructive pulmonary disease (COPD) | Consultant leader 1 project leader (Health care consultant) | Find and recommend an effective ICT system and an expert COPD training team visiting each practice |
GP practice group | Multi-morbidity | Consultant leaders 2 project leaders (MD, RN) | Develop integrated approaches for the management of co-morbidity and chronic illness |