A Chronic Disease Management (CDM) Nurse assists the
doctor(s) through one or more of the four components that make up the Panel
Individuals who are required to completed blood work at a
regular interval based on CDM standards. These patients will be reminded by the
CDM Nurse when they are due to go and will be able to inform and discuss their
blood work results with them.
Individuals who are eligible for certain cancer and
co-morbidities screenings are told of what they should having checked after the
CDM Nurse has reviewed client medical files.
Individuals can be referred to this group to better manage
an acute phase where they need more frequent monitoring than the physician can
Complex Care Plans (CCPs)
Individuals will receive a comprehensive review of their
medication and lifestyle practices. An emphasis is made on setting goals that
will increase their quality of life and better manage their conditions. Goals
are determined between the patient and their physician, then monitored and
assisted by the CDM Nurse.
Plans are completed annually and observe the identifiable
changes in overall health, whether it be positive or
The delivery and availability of these components will vary