Revolutionizing care for patients with multiple chronic conditions


Almost 80 per cent of Ontarians over the age of 45 have at least one chronic condition such as diabetes, heart disease, depression, cancer and arthritis. And a growing number of people are living with more than one chronic condition. What’s more, 20 per cent of those living with multiple chronic conditions are readmitted to hospital within 90 days of being discharged.

The good news is that many of these people can live long, productive and independent lives at home, without needing in-patient hospital care. What they do need, however, is support and education on how to manage their diseases, so they don’t end up in an emergency room.

That’s why Women’s College Hospital, in collaboration with the University of Toronto, has launched an innovative new program, the Centre for Ambulatory Care Education (CACE) Complex Care Clinic. The program, which launched July 19, 2011, offers patients with complex medical conditions an interprofessional team with expertise in chronic disease management.

“Our goal is to keep patients out of emergency rooms, avoid hospital readmissions and improve patients’ health by helping them manage their diseases,” says Dr. Tina Borschel, medical director for the clinic andUniversityofTorontointernal medicine lead for ambulatory education.

The CACE Complex Care Clinic is part of a new model of care aimed at providing a seamless transition from acute (in-patient) settings to ambulatory environments where patients manage their illnesses without needing hospitalization. The clinic supports patients who have been discharged from programs like Women’sCollegeHospital’s Unit for Intensive Ambulatory Care and Virtual Ward, offering longitudinal followup care for complex cases.

“Although our clinic just opened, we have already seen a handful of patients who need a lot of specialized care,” explains Borschel. “And our team is able to help them better manage their health by providing consistent interprofessional care with linkages to community resources, while supporting their family physicians’ ability to care for these complex patients.”

The interprofessional team – composed of general internal medicine and family practice physicians and residents, a nurse, pharmacist, dietitian, occupational therapist, physiotherapist, respiratory therapist, social worker, medical secretary and community care access providers – is able to address all of a patient’s chronic medical conditions at the same time, in the same place.

To ensure an integrated approach, the clinic team works in collaboration with the Toronto Academic Health Sciences Network (TAHSN) of hospitals and the Toronto Community Care Access Centre (CCAC), as well as with other specialists and family physicians.

What’s more, the CACE Complex Care Clinic is designed to educate future health-care professionals about chronic disease models of care, with a focus on interprofessional care.

The Clinic provides a unique learning opportunity for residents and other health-care trainees working in an ambulatory setting who traditionally would not follow chronic disease ambulatory (‘out’) patients on an ongoing basis. The CACE Complex Care Clinic, however, allows trainees to follow patients’ care over time, creating a ready supply of health-care professionals who are expert in ambulatory care – where most health care happens.

“This is an opportunity that residents don’t often get,” explains Theresa Kay, interim director of CACE. “Not only do they get the opportunity to learn each patient’s medical history, and work with the same patients on an ongoing basis, but they are also part of an interdisciplinary team, which allows them to be introduced to different areas of health care they may otherwise never see.”

Already, the benefits of the program are far-reaching. Both students and patients have benefited from the interdisciplinary approach. Patients have expressed their appreciation for being able to see a number of health providers at one appointment, and trainees have learned a great deal by having access to health-care professionals outside their area of focus.

“We believe our program will not only transform care for patients seen here at Women’s College Hospital, but also for patients everywhere as we train the next generation of health professionals to be experts in the area of chronic disease management,” adds Kay.