A Chronic Disease Management (CDM) Nurse assists the doctor(s) through one or more of the four components that make up the Panel Management Program:
- 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.
- Management Group
- Individuals can be referred to this group to better manage an acute phase where they need more frequent monitoring than the physician can accommodate.
- 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 negative.
The delivery and availability of these components will vary by clinic.