What's covered

The World Health Organization states (2008) that the top four chronic non-communicable conditions (cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes) cause an estimated 35 million deaths each year. It goes on to project that this will increase by 17 percent over the next ten years.

A population health approach focuses on improving the health status of the population by directing action at the entire population, or sub-population, rather than individuals. It is important to recognize the complex interplay between population health and multiple determinants of health such as socioeconomic status, geography, age, gender, and culture. This calls for innovative and interconnected strategies to maintain and improve the health and well-being of the population as a whole.

Most services for those with chronic conditions are delivered by primary care providers in the community. These standards address the importance of aligning and integrating chronic condition management policies and strategies across the continuum of care, and supporting primary care service providers.

HSO’s standards for populations with chronic conditions are based on Wagner et al’s Chronic Care Model.

The standards contain the following sections:

  • Investing in chronic condition management services
  • Partnering with the community to promote health and wellness
  • Integrating and coordinating health services for populations with chronic conditions across the continuum of care
  • Basing decisions on research and evidence
  • Using information and information technology
  • Monitoring quality and achieving positive outcomes

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