Speaker 1: The Chronic Disease Management Nurse Coordinator Program is an innovative and simple path available to North Shore-based family physicians caring for patients with multiple complex health conditions. Patients appropriate for referral to the program include those with two or more chronic conditions and who may also be facing broader determinants of health. This program supports increased collaboration and coordination between family physicians and VCH's chronic care services. In addition, the program can connect patients to appropriate community resources for their housing and social support needs. When a physician refers their patient to our program, our office will call the patient directly and book them for an initial appointment with the Chronic Disease Management Nurse Coordinator, or CDM for short. The patient is encouraged to attend their appointment with a family member or caregiver. All appointments with the CDM take place at West Vancouver Community Health Centre.

Speaker 2: The program has definitely been helpful. The knowledge that there was someone familiar with my condition available to contact for assistance was especially reassuring. We were also referred to a coastal health dietician for assistance with meal planning and snack recommendations.

Speaker 1: During their first visit, the CDM performs a baseline physical assessment on the patient, reviews their medications, assesses their psychosocial needs and refers them to other community services as appropriate. One-on-one education on their health conditions, including an understanding of their medications, lab and diagnostic results is also provided.

Speaker 2: The thorough education session that my wife and I participated in gave us a lot of confidence that we would be able to thoroughly manage the therapy.

Speaker 1: The patient will then be scheduled for ongoing follow-up with the CDM.

Speaker 3: The patients we see have multiple complex health conditions, usually four or five significant issues. This program enables us to spend more time with patients who need detailed, customized help that can't be covered in a 15-minute consult.

Speaker 4: The service has assisted me in reaching targets with more of my patients, while reviewing important results, which I cannot realistically ensure and accomplish given the numbers and the time required for these patients.

Speaker 3: We can help patients understand why their doctor has recommended or prescribed a certain treatment or approach. We give them options on how to manage their condition and they make their own choices, which can be incredibly powerful for people who are potentially quite ill.

Speaker 1: Providers can refer to the program using the latest version of our North Shore Chronic Disease Services referral form. Please also let your patients know you're referring them to the program and that they can expect a call from our office to schedule their appointment with the CDM.