Case Study: Effective home management of chronic disease
A health and social services centre in Eastern Québec offers telemonitoring for chronic obstructive pulmonary disease
An increasing number of Canadians are living with chronic diseases, which now account for over two thirds of direct healthcare costs. Diabetes, respiratory disease, heart failure and hypertension are among the most common. These patients are often referred to community-based home care services that aim to manage symptoms proactively to improve functional capacity and prevent exacerbations that lead to ER visits and/or hospitalizations.
In Québec, home care is largely the responsibility of the CLSCs (local community health centres), which are grouped administratively under Centres de la Santé et des Services sociaux (CSSS) and receive funding from the ministère de la Santé et des Services sociaux (MSSS). In 2006, the CSSS Grand Littoral in Eastern Québec, which serves a population of over 221,000 spread over close to 5,000 km2, conducted a review of its services and found that poor coordination of care for home-based patients with chronic disease stood out as a significant problem.
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