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Patients with chronic conditions get one-stop care

For the first time in Canada, patients with chronic conditions - such as diabetes, high blood pressure or heart failure - will soon be able to do one-stop shopping for all their medical needs.

"The population that we're caring for is increasingly aging and living with multiple medical problems," said Gillian Hawker, chief of medicine at Women's College Hospital. "But our health-care system hasn't been set up to deal with multiple chronic conditions."

That's why Women's College Hospital in Toronto is opening the Centre for Ambulatory Care and Education Complex Care Clinic on July 19. It is now taking referrals from physicians and community-care access centres for patients with one or more chronic illnesses.

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An estimated 16 million Canadians live with at least one chronic condition; some live with more than one, necessitating referrals to multiple medical specialists. Others lack proper care until a health crisis hits. Some have no physicians and are dubbed "frequent fliers" for their constant use of emergency.

Under the new clinic, a patient with heart failure, chronic obstructive pulmonary disease and diabetes, for example, who is seeing a cardiologist endocrinologist and respirologist could have her care managed at the clinic.

It makes good fiscal sense for the health-care system, too, as one per cent of the population consumes 50 per cent of health costs due to hospitalization and home-care use, according to Dr. Hawker.

Having doctors, nurses, pharmacists, dieticians and physiotherapists all in the same area to treat patients may sound like common sense, but Canadian hospitals aren't organized that way. That's because the system is focused on those who provide care, not those who receive it.

Tina Borschel, medical director of the new clinic, said she expects the facility to see about 75 patients a week. About a third of these patients are not likely to have a family doctor.

"It may be a patient who has diabetes and high blood pressure and chronic kidney disease, and perhaps who has had several hospitalizations in the year and then comes in to be followed in the clinic," said Dr. Borschel.

Occupational therapists, social workers, respiratory therapists and internal medicine specialists will also be available to treat patients. Many, but not all, of the patients will be elderly.

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Theresa Kay, interim director of the centre, said patients will also be given a care plan they can take with them "so that they are really involved in what their care is and they have a role within that."

Louise Nasmith co-chaired a report published in December called Transforming Care for Canadians with Chronic Conditions, done by the Canadian Academy of Health Sciences, a not-for-profit scientific group.

One suggestion was that patients with chronic health conditions be able to access care with a team of clinicians who can co-ordinate those services throughout their lives.

"What often happens is you have the frequent fliers in the emergency departments or they are frequent fliers in hospitalizations and end up being readmitted [to hospital]more than they actually should be," Dr. Nasmith, professor and principal of the College of Health Disciplines at the University of British Columbia, said in a telephone interview from Kelowna.

Oftentimes, these patients have more than one chronic disease - diabetes plus mental-health issues such as depression, as one example - which can make their treatment more complex.

For patients, their care is disjointed and means going from one appointment to another over a period of weeks or months with various specialists.

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"I do believe government recognizes this is a huge issue," said Dr. Nasmith.

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