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Improve Care for Individuals With/At Risk of CV Disease

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Brief Overview of Clinical Issue

Coronary artery disease (CAD) is a significant public health problem, it is a major cause of morbidity and mortality among adults, and it causes a substantial economic burden to societies. Coronary artery disease is a multifactorial disease, influenced in part by diabetes. Every 8 minutes a person is diagnosed with diabetes in Canada, and it has reached epidemic proportions among Indigenous peoples. In Canada, there are care gaps between clinical goals outlined in evidence-based guidelines and real-life clinical practice settings.

The chronic care model (CCM) is an organization approach as well as a quality improvement strategy designed to improve care for individuals with chronic disease. Elements of the CCM facilitate planning and coordination among providers while helping patients play an informed role in managing their care. Individuals who practice self-management, supported by an interprofessional team, take an active part in the management of their condition through problem solving, decision-making, action planning, self-tailoring, and the formation of patient-provider partnerships.

Delivery System Design

Self-Management Support

Decision Support

Student Research

Related Publications