The Chronic Disease Prevention and Management Program includes Northwest Regional Renal Program, the Centre for Complex Diabetes Care, the Bariatric Care Centre and the Internal Medicine Clinics. The Medicine Service includes Inpatient Units 2A Renal and Medicine Care; 2B Chronic Disease, Clinical Teaching Unit and Medicine Care; and 3TM Medical Short Stay Unit, as well as the Hospitalist Service. The new combined Program and Service focuses on four diseases/ conditions: chronic kidney disease, diabetes, obstructive lung diseases (COPD & asthma) and obesity. Our Strategic Direction will be based on Ontario’s chronic care model, spanning the full patient continuum and integrating primary to tertiary care assessment and management. The Program/Service also provides leadership for the Admitting department, administrative coordinators, local ground patient transportation, and the Nurse-Led Outreach teams.

Health Status

Northwestern Ontario has higher-than-average incidence of chronic disease including diabetes, pulmonary diseases, and renal disease. Incidence rates are particularly high among Indigenous peoples. The region also has higher incidence of risk factors including tobacco use, alcohol use and obesity. Chronic diseases tend to have a compounding effect. Complications of illness can also lead to other serious health issues. For example, diabetes can lead to renal failure, loss of eyesight of amputation. The Chronic Disease Prevention and Management Program is developing new screening and prevention programs as well as new initiatives to empower patients with the skills and confidence necessary to manage aspects of their chronic diseases with their healthcare providers.

Patient Outcomes

  • Over 3,400 patients without a family doctor, or orphan patients, per year (20% of all patients at TBRHSC) receive care from the Hospitalist Service;
  • Funds from the Ontario Renal Network allowed the Renal Service to hire Body Access and Independent Dialysis Coordinators who have worked hard to promote and increase home dialysis rates and increase vascular access rates;
  • Our home rates have been some of the best in the province, meaning patients receive excellent care at home;
  • Patients have also been able to receive care at home thanks to new Telehomecare Equipment with funding from the Local Health Integration Networks.