This initiative is designed to address the disproportionately large number of patients within Mosaic's boundaries who have chronic diseases. Chronic disease is a health condition that can be managed or improved but not cured (e.g. asthma, diabetes, COPD). Complex care patients are those with 2 or more chronic diseases at the same time, which requires coordinated treatment. The Mosaic PCN recently added several new programs within this initiative, including a Mosaic Community Clinic to enhance the current chronic disease programs available through member physician's offices.
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Also, a Cardiac Rehabilitation Program provides improved continuity of care for those who have suffered a heart attack.
This program operates in the northeast in order to ease transporation difficulties that community members currently face when referred to this program downtown.
Lastly, Mosaic will establish a Chronic Pain Clinic to help patients in Mosaic's boundaries manage this common issue. |
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HELPFUL LINK FROM:
MULTICULTURAL RESOURCES! |
Chronic Disease Management (CDM) Nurses:
As part of the services that Mosaic PCN offers, CDM nurses play a large role in managing chronic disease issues within Mosaic physician's offices. Together with the physicians, CDM nurses assist with case management, referrals to appropriate services, and provision of disease management according to clinical practice guidelines.
The purpose and goal of this service is to help patients with chronic disease or complex care needs to manage their disease(s) and to live as independently as possible. The focus of this program has continued to be on poorly controlled diabetes, pre-diabetes, hypertension and dyslipidemia. Other diseases that Mosaic PCN also addresses are Chronic Obstructive Pulmonary Disease (COPD) and asthma.
To increase physician awareness and referrals, Mosaic works closely with the Living Well Program, and will be working with the Calgary COPD and Asthma Program (CCAP) and the Calgary Pediatric Asthma Service - all offered through AHS. These partnerships provide several options for Mosaic community members to access pulmonary rehabilitation therapy as needed.
Mosaic PCN also employs many other allied health professionals that provide chronic disease expertise, including a chronic disease dietitian, pharmacist, and Nurse Practitioner. To access these resources, talk with your family physician or, if you do not have a family physician, make an appointment at the Mosaic Primary Care Clinic.
Support for CDM at the Peter Lougheed Centre (PLC):
Mosaic PCN believes it is important to support the PLC. Currently, we assist PLC patients with the transition from acute care to primary care. This transition occurs when patients at PLC no longer need acute care (in-hospital) services but require follow-up care to ensure and facilitate their recovery, which is where primary care services are essential. To ease this transition, Mosaic member physicians accept complex care patients from the Complex Chronic Disease Clinic at PLC in an effort to reduce readmission of these patients due to lack of follow up and primary care.