Women's College Hospital - Health Care for Women, Revolutionized

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Revolutionizing care for patients with multiple chronic conditions

from the June 13, 2011 issue of Connect

Revolutionizing care for patients with multiple chronic conditions

Almost 80 per cent of Ontarians over the age of 45 have at least one chronic condition – like diabetes, heart disease, depression, cancer and arthritis – and a growing number of people are living with more than one chronic condition. What’s more, 20 per cent of patients living with multiple chronic conditions are readmitted to hospital within 90 days of being discharged.

The good news is that many of these patients can live long, healthy and independent lives at home, without needing in-patient hospitalization. What they do need however is support and education on how to manage their diseases, so they don’t end up in an emergency room.

That’s why Women's College Hospital, in collaboration with the University of Toronto, is introducing an innovative new program, the Centre for Ambulatory Care Education (CACE) Complex Care Clinic.  Opening in July 2011, it will offer patients with complex medical conditions an interprofessional team with expertise in chronic disease management.

“Our goal is to keep patients out of emergency rooms, avoiding hospital readmissions and improving patients’ health by helping them manage their own diseases,” says Dr. Tina Borschel, medical director for the clinic and University of Toronto internal medicine lead for ambulatory education.

The interprofessional team – comprised of general internal medicine and family practice physicians and residents, a nurse, pharmacist, dietitian, occupational therapist, physiotherapist, respiratory therapist, social worker, medical secretary and community care access providers – will treat all of a patient’s chronic medical conditions at the same time, in the same place.  They’ll also help patients improve their own health through self-management techniques.

The team will work in collaboration with the Toronto Academic Health Sciences Network (TAHSN) of hospitals, including University Health Network (UHN), and the Toronto Community Care Access Centre (CCAC), as well as with other specialists and family physicians to ensure the most integrated and seamless care.

What’s more, the CACE Complex Care Clinic is designed to educate future health-care professionals about chronic disease models of care, with a focus on interprofessional care.

“We believe our program will not only transform care for patients seen here at Women's College Hospital, but also for patients everywhere as we train the next generation of health professionals to be experts in the area of chronic disease management,” adds Theresa Kay, interim director of CACE.

 Some of the members of the CACE Complex Care Clinic team
Some of the members of the CACE Complex Care Clinic team


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