Chronic Disease Prevention and Management

In Ontario the top 5% of our patients consumes 66% of our health care spending. It is essential that we improve the patient experience and overall population health through better care coordination, enhanced care quality and standardization of evidence-based care pathways to achieve better health outcomes. We are committed to advancing and implementing CDM care pathways and service delivery models to better support our highest users of healthcare in achieving positive health outcomes.


In order to improve the overall patient experience and population health while containing costs, there is a need to effectively manage their conditions through health system transformation.






Future State:

Care for these individuals is complex, most have multiple conditions and uncoordinated disease management programs are not effective. All providers need to work differently to ensure that effective transitions in care, enhanced relationships and coordinated case management occurs with all system providers across the continuum of care.  There is a need to innovatively design and enhance collaborative initiatives that will allow for a measureable and positive impact on patient/client including:

  • Improve the patient experience and achieve better patient health outcomes
  • Improve health care delivery (ie, appropriate system utilization, improved care coordination, improved transitions of care, etc.)
  • Ensure development of coordinated care plans for all complex patients
  • Reduce average cost of delivering care without compromising quality
  • Increase the number of complex patients and seniors with regular, timely access to primary care
  • Reduce avoidable ED visits when condition is best managed elsewhere
  • Reduce 30 day hospital re-admission rates
  • Reduce unnecessary hospital admissions
  • Reduce hospital ALC rates
  • Improve ED wait times and appropriate ED utilization