Chronic disease management (CDM) programs are well and thriving in Primary Care Networks (PCN) across Alberta with patients often receiving faster access, more regular check-ups and standardized care, and tools and education that help them become partners in managing their own health.

PCNs were first established in 2003 to improve access to family physicians and other frontline health care professionals. Today, there are 29 PCNs operating throughout the province with another nine in the planning stages.

PCNs are a made-in-Alberta approach to improve the delivery of primary care. A PCN is formed when a group of physicians and Alberta Health Services agree to work together to provide enhanced primary care services. This groundbreaking approach to primary care delivery was made possible by the trilateral agreement between Alberta Health and Wellness, Alberta Medical Association and Alberta Health Services.

One of the key services driving the implementation of PCNs was CDM services. As the population ages, many people are diagnosed with multiple health problems: heart disease, diabetes, emphysema. Several studies done over the past several years identify CDM as a major challenge for health systems overall, and the need for standardized, integrated and timely care to adequately address the issue.

In Alberta, PCNs have implemented comprehensive, integrated CDM programs. The result is a patient's quality of life is often improved and the pressure on the health system reduced.

While the process to access CDM services varies depending on the PCN, everyone agrees that patients are benefiting, regardless of the location.

Rosalynn Hetherington, a CDM nurse in the Calgary Rural PCN explains that rural PCNs usually have a central contact point, one person who coordinates the needs of patients with complex health needs. CDM Coordinator Aimee Poole, from the Wood Buffalo PCN, has a similar role with physicians in the Fort McMurray area referring patients from their specific office locations to the central PCN clinic office.

In the case of the Sexsmith PCN, there are major issues in finding available resources which require some innovative approaches for delivery of health services. Yong Shi, Primary Care Coordinator in Peace Country, points out that only three physicians work in the PCN so they hired a registered nurse and licensed practical nurse to support the physicians and help manage patients with complex health needs.

In all three PCNs, shared medical appointment sessions for health issues such as diabetes are improving access for patients while helping them better understand the major role they can play in managing their own health.

Poole from the Wood Buffalo PCN mentions a group medical appointment where one of the patients was not eating the right food and doing the necessary physical activity. In the session, another patient could relate to the person's challenges and offered some possible suggestions for improving compliance.

Shared medical appointments are often held on Saturdays and Sundays for about 20 to 30 patients with complex health needs in the Sexsmith PCN. "Our experience so far," says Shi, "is that the patients like them: they're efficient and people have many similar questions and concerns."

Many PCNs offer shared medical appointment sessions for patients with chronic disease such as heart disease, diabetes and proper use of medications. In virtually all cases, the sessions follow clinically-recognized, standardized models that studies show make a real difference in a person's health.

And from the physician perspective, CDM programs in PCNs are the way to go. Dr. Leslie Cunning, Physician Lead for the Calgary Rural PCN sees great gains being made in the area of CDM and the potential for more well into the future. "We're starting to see treatment for diabetes being standardized," he says.

At the Edmonton Southside PCN, the primary care nurses are located right in the family physician clinics and support those patients seen by the family doctor. Diabetic patients have been the nurses' initial focus, although patients with other chronic diseases are often monitored by the nurses in collaboration with the family physician.

Dr. Oliver Seifert from the Edmonton Southside PCN supports Dr. Cunning's observations, citing the involvement of Kate Miner, a registered nurse who works in his clinic. "Kate has helped me tremendously with sorting out my diabetic patients. She is the biggest asset that the PCN has contributed to my practice," says Dr. Seifert.

Primary Care Networks (PCNs) are a made-in-Alberta approach to improve the delivery of primary care. A Primary Care Network is formed when a group of physicians and Alberta Health Services agree to work together to provide enhanced primary care services. In addition to physicians, other health professionals are key partners in delivering PCN services. Alberta Health and Wellness, Alberta Medical Association and Alberta Health Services are partners in the development of Primary Care Networks.

For further information: Leslie Beard, ((780) 952-2033) Or Primary Care Initiative Office, Toll Free: 1-866-714-5724