Chronic Disease Management Toolkit - Learning Outcomes

Group learning sessions are available in most local communities. They are designed to help Clinical practices implement and maintain quality improvements, as well as provide participants with opportunities to network with colleagues.

Adopting the CDM Toolkit is one component of the "CDM Bundle", a series of learning sessions specifically related to issues in chronic disease management (CDM). There are 6-8 learning sessions in the CDM "bundle", with each session 3.5 hours in duration.

Each learning session is followed by an action period, in which session participants can implement and experiment with the improvements in their own practice. Support is available from the regional Practice Support Teams for any issues that may arise during this time, such as help identify barriers, track progress, exchange information, address sustainability and motivate participants. Support can also include help with paperwork for funding, eligibility, reimbursement and policy.

Physicians and MOAs will be compensated for their investment in making changes in their practices. Learning Sessions and Action Periods are paid at GP sessional rates. MOA time is compensated at $20/hour as an expense to the GP.

After completing the learning sessions for Adopting the CDM Toolkit, practices will be able to:

• Identify the functions and benefits of the Toolkit for a specific Clinical practice
• Assess system capabilities for implementing the Toolkit
• Create an action plan and working team
• Import patient data from Electronic Medical Records (EMR) software
• Use flowsheets to provide evidence-based, guideline-directed care for chronic disease patients
• Use practice-based analysis tools to identify and monitor gaps in care
• Share secure patient data with other members of the patient care team
• Generate reports to profile the practice and compare patient outcomes with other populations
• Integrate the Toolkit with practice workflow
• Maximize the Clinical value of Toolkit reports and tools
• Measure how the Toolkit is improving care management
• Contact the appropriate resources for help using the Toolkit