John Dorland is assistant professor, Community Health and Epidemiology, Queen's University.

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Mary Ann McColl is professor, Department of Community Health and Epidemiology, and associate director, Research, Centre for Health Services & Policy Research, Queen's University.

Emerging Approaches to Chronic Disease Management in Primary Health Care
Edited by John Dorland and Mary Ann McColl

Table of Contents


of Tables and Figures ix
Foreword-Chronic Disease: Our Growing Challenge xi
Michael Decter
Acknowledgements xiii
Introduction to Chronic Disease Management in Canada xv
John Dorland and Mary Ann McColl

A Theoretical Framework
I. The Chronic Care Model 3
Michael Hindmarsh

Leading Programs in Chronic Disease Management
2. Improving Population Health and Chronic Disease Management 15
Paul Wallace and Joshua Seidman
3. Chronic Disease Management-PLUS 21
Art Macgregor
4. Chronic Disease Management in a Comprehensive, Integrated Primary Care Setting 31
David Crookston and Elizabeth Bodnar
5. Developing Chronic Disease Policy in England 39
Rebecca Rosen

Canadian Initiatives in Chronic Disease Management
6. An Ounce of Prevention: Integrating Clinical Prevention into Family Practice in British Columbia 53
Shannon Turner
7. The Saskatchewan Chronic Disease Management Collaborative 63
Ben Chan
8. The Chronic Disease Self-Management Program in British Columbia 79
Patrick McGowan
9. Getting a Grip on Arthritis: A National Primary 1Iealth Care Community Initiative 91
Sydney Lineker, Mary I. Bell, Jennifer Boyle, and
Elizabeth Badley
10. The Leader Diabetes Initiative: Optimizing Diabetes Care in Saskatchewan 101
Mikki Millar
II. Chronic Disease Management: Diabetes Integration Initiative 107
Angela Estey, Richard Lewanczuk, and Marianne Stewart
12. The Canadian Home Care Association's National Home Care and Primary Health Care Partnership Project 113
Marg McAlister and Nadine Henningsen
13. Chronic Disease Prevention, Management Collaboratives and Primary Health Care in Newfoundland 123
Juanita Barrett and Ann Colbourne
14. Managing Chronic Mental Health Problems in Primary Care: The Hamilton Health Services Organization Mental Health and Nutrition Program 131
Nick Kates
15. Implementing a Chronic Disease Management Program Without Totally Redesigning the Current System 139
Sandra Delon
16. A Novel Approach to Cardiovascular Health by Optimizing Risk Management-ANCHOR 145
Brendan Carr, Jafna Cox, Blair 0' Neill, Michael Vallis, and Claudine Szpilfogel
17. A Telehealth Approach to the Management of Congestive Heart Failure 155
Paul Nyhof

Synthesis and Conclusion
18. Synthesis of Report-Back Session at the National Chronic Disease Management Conference April 6-7, 2006, Toronto 167
Michael Hindmarsh and Nick Kates
19. Conclusion and Directions for the Future 171
Mary Ann McCo11 and John Dorland

Appendix: Contributors to the Conference
Organization 181
Glossary of Medical Terms 185
Biographies 189