Chronic Disease Management and Prevention

Chronic diseases are among the most common and costly health problems facing Canadians; they are also among the most preventable. Chronic diseases on the Canadian Chronic Disease Surveillance System include:            

  • Diabetes
  • Chronic respiratory diseases – asthma and chronic obstructive pulmonary disease
  • Cardiovascular diseases – including stroke, hypertension and heart failure
  • Mental illness
  • Musculoskeletal disorders
  • Neurological conditions – including dementia                      

Anchored by Ontario’s Framework for Preventing and Managing Chronic Disease, and in collaboration with our partners, we seek to identify opportunities to support provincial priorities, encourage healthy living and support best practice management of complex conditions along the continuum of care - from prevention and early detection to the end of life. Here are some resources to support individuals with chronic diseases.

Chronic Condition Supports

  1. Find A Doctor – Chronic condition services and programs are available from health care providers in a variety of settings.

  2. Living a Healthy Life with Chronic Conditions Workshops – These ongoing six-week workshops offer self-management workshop to help individuals living with chronic health issues as well as their caregivers.

  3. Inter-Professional Care Teams -- Bring together a diverse group of health care experts (doctors, nurse practitioners, registered nurses, dietitians, physician assistants, pharmacists, mental health workers, social workers, psychologists, physiotherapists, chiropractors and others) to support improved patient experience, timely access to care and chronic disease management. Across our communities, inter-professional care services are offered by Black Creek Community Health Centre, Vaughan Community Health Centre and Health for All Family Health Team. Primary Care Providers are invited to refer patients.

 4. Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF)

  • Telehomecare is a six-month self-management program that helps patients self-monitor their illness and better manage their symptoms. Telehomecare registered nurses provide patients with health coaching and education, guiding them in setting achievable goals. Patients take their vital signs using a blood pressure cuff, pulse oximeter, weight scale, then send the results to the nurse via tablet for monitoring.
  • Telehomecare complements care from primary care providers, as exacerbations can be caught early, avoiding unnecessary visits to the hospital or emergency department
  • For more information or to enroll/refer a patient

5. Diabetes

6. Chronic Kidney Disease (CKD)

  • CKD is a type of disease in which there is gradual loss of kidney function over months or years, and may lead to kidney failure. Potential causes of kidney failure include diabetes or high blood pressure among other conditions.
  • The Ontario Renal Network (ORN) is responsible for planning consistent standards and guidelines, putting in place information systems, and funding renal services in Ontario with an aim to reduce the burden of this disease. It operates 14 regional programs.
  • For Primary Care Providers within our communities: For information on Regional Renal services and planning, contact Regional Director Susan Mason (Humber River Hospital) or Regional Medical Lead Dr. Michael Pandes (Mackenzie Health).

7. Cancer

  • The Central Regional Cancer Program, hosted by Southlake Regional Health Centre, oversees the quality and delivery of cancer services for residents across North York, York Region and South Simcoe. Southlake’s cancer centre offers in-patient and out-patient cancer care services.
  • The Central Regional Cancer Program partners with other hospitals: Humber River Hospital, Markham Stouffville Hospital, Mackenzie Health, North York General Hospital and Stevenson Memorial. Together, these hospitals offer an array of cancer treatment and supportive care programs for patients and their families.

8. Stroke

9. Mental Health

10. Musculoskeletal Disorders

  • One in three adults live with musculoskeletal (MSK) conditions – which can affect muscles, bones or joints, and cause pain and mobility issues.
  • A new model of care was launched in 2018/19 to improve quality, access and appropriateness of care for people with MSK conditions, starting with referrals for primary hip and knee arthroplasty.
  • Learn more about the MSK Central Intake, Assessment and Management model, which plans to expand to include pathways for all other MSK conditions.