CHF/COPD Pathway
Who is this for?
The Chronic Disease Management Program (CDMP) supports individuals living with complex chronic health conditions, with an initial focus on heart failure (HF) and chronic obstructive pulmonary disease (COPD).
Pathway Information
Patients will receive a comprehensive assessment, individualized care plan, self-management education, ongoing follow-up, and connections to community supports as needed. Referring clinicians will receive regular updates on their patients' progress.
The Chronic Disease Management Program's referral form is available as a PDF or PS Suite custom form.
Download the CDMP's Referral Form:
Workflow
Additional Information
Patient/Client Facing Resources
Clinical Context
Best Practice
Health Quality Ontario:
- Heart Failure: Care in the Community for Adults - addresses care for adults who have heart failure, including the assessment and diagnosis of people with suspected heart failure. It applies to community settings, including primary care, specialist care, home care, hospital outpatient clinics, and long-term care. (Quality Standard Details | Ontario Health)
- Chronic Obstructive Pulmonary Disease COPD - addresses care for people with COPD, including the assessment of people who may have COPD. It provides guidance on the diagnosis, management, and treatment of COPD in community-based settings. The scope of this quality standard applies to primary care, specialist care, home care, and long-term care. (Quality Standard Details | Ontario Health)
Need Help and Feedback
If you need assistance with any part of this pathway, including understanding the process, accessing forms, digital implementation, or reporting technical issues, please contact us. We welcome your feedback and suggestions for improvement.
info@klhpcn.ca
Please expect a response in 1-2 business days.
Total
28.5 hours over a minimum of 6 weeks
