Complete guide to Canadian hospital chronic disease management — diabetes, cardiovascular disease, COPD, mental health, chronic disease strategy, self-management programmes, telehealth, and chronic disease software.
Chronic diseases account for 60% of Canadian healthcare costs. 3M+ Canadians have diabetes. 1 in 5 have mental health issues. This guide covers Canadian chronic disease management.
Chronic Disease Management Model
| Component | Description | Provider |
|---|---|---|
| Screening | Risk assessment and early detection | Primary care |
| Diagnosis | Confirm diagnosis and assess severity | Primary care + specialist |
| Care plan | Individualised care plan with goals | Multi-disciplinary team |
| Self-management | Patient education and self-management support | Patient + team |
| Monitoring | Regular monitoring of condition and risk factors | Primary care + specialist |
| Telehealth | Remote monitoring and virtual follow-up | Telehealth platform |
| Coordination | Care coordination between providers | Care coordinator |
| Acute management | Manage acute exacerbations | Hospital + ED |
Diabetes Management
- Screening: CANRISK tool for adults 40+, HbA1c for at-risk patients
- Diagnosis: HbA1c >= 6.5%, fasting glucose >= 7.0, OGTT >= 11.1
- Lifestyle: Diet, exercise, weight management
- Medication: Metformin first-line, SGLT2 inhibitors, GLP-1 agonists, insulin
- Monitoring: HbA1c every 3-6 months, annual eye/foot/kidney check
- Technology: CGM, insulin pump, telehealth follow-up
- Self-management: Diabetes self-management education (DSME)
CVD Management
- Risk assessment: Framingham or Canadian CV Risk score
- Primary prevention: Lifestyle, statins for high risk, BP control
- Secondary prevention: Antiplatelet, statin, beta-blocker, ACEi
- Cardiac rehab: Structured cardiac rehab programme
- Heart failure: GDMT — ACEi/ARB, beta-blocker, MRA, SGLT2i
- AF: Anticoagulation (DOAC), rate/rhythm control
- Telehealth: Remote monitoring for heart failure and hypertension
Frequently Asked Questions
- What is the chronic disease burden in Canada?
- Chronic diseases are the leading cause of death in Canada: 1) CVD — 20% of deaths, 2. Cancer — 28% of deaths, 3. Diabetes — 3M+ Canadians (8% prevalence), 4. COPD — 2M+ Canadians, 5. Mental health — 1 in 5 Canadians. Chronic diseases account for 60% of healthcare costs. Risk factors: smoking (14%), obesity (28%), physical inactivity (50%).
- What is the Canadian chronic disease strategy?
- Canada's chronic disease strategy (Public Health Agency of Canada): 1) Prevention — healthy living, tobacco control, food policy, 2. Early detection — screening programmes, 3. Management — chronic disease management programmes, self-management support, 4. Surveillance — Canadian Chronic Disease Surveillance System (CCDSS), 5. Research — CIHR funding for chronic disease research.
- How does telehealth support chronic disease management in Canada?
- Canadian telehealth for chronic disease: 1) Remote monitoring (BP, glucose, weight, SpO2), 2. Virtual consultations for chronic disease follow-up, 3. Tele-education for self-management, 4. Telepharmacy for medication management, 5. Tele-rehabilitation for cardiac and pulmonary rehab. Telehealth improves access, especially in rural/remote areas, and reduces hospitalisations by 20-30%.