Chronic disease management (CDM) Quality Care

The CDM COPD Quality Care initiative consists of a guide on how to improve the quality of patient care that is delivered and to develop better management practices, using a given chronic condition (COPD) as an illustration. This Web site will take you, step by step (a six-step process), through the CDM approach, and provide you with appropriate explanations (justifications, pitfalls, case studies) and specific tools that you may want to use and adapt to your needs.


A guide to the development and implementation of an effective approach to chronic care

Based on the successful approach developed at the Montreal Chest Institute of the McGill University Health Centre (MUHC), the proposed chronic disease management (CDM) Quality Care approach, which has integrated numerous elements from other initiatives across Canada, is a guide to the development and implementation of an effective chronic care approach to effecting quality improvements to your institution. Health care professionals and managers who want to examine and improve the organization and quality of COPD patient care in their institutions will find much to interest them on the CDM COPD Quality Care Web site.

To manage the chronic conditions of
high-risk, high-cost patients

  • This CDM Quality Care Web site is designed to guide you through assessing and optimizing chronic care delivery and practices (specific interventions, programs, pathways); and
  • Continuously improving the quality of the care your hospital delivers to COPD patients (emergency room and admissions) to reach the level of evidence-based guidelines (knowledge translation).


Fundamental to this Quality Care Web site, we advocate the DM approach: "a system designed to manage the chronic conditions of high-risk, high-cost patients as a group".


Definition of Disease Management (DM)

There are many definitions of DM. Earlier definitions have laid the foundations of what we essentially mean by DM:

"Disease management refers to the use of an explicit systematic population-based approach to identify persons at risk, intervene with specific programs of care, and measure clinical and other outcomes." (Epstein and Sherwood, 1996.)

Many elements in the "modern" definition are considered as part of DM1:

  1. focusing on a target group
  2. of persons with chronic diseases
  3. with the goal of improving clinical outcomes and quality
  4. cost-effectiveness of the care delivered
  5. by means of a systematic approach
  6. with preventive (exacerbations, complications) and evidence-based interventions
  7. in which self-management by patients is given an important role
  8. provided by a multidisciplinary professional team.
  9. including continuous evaluation (clinical, personal, economic)


Knowledge translation (KT)

The primary purpose of KT is to address the gap between research data and its systematic review and implementation by key stakeholders (evidence-based guidelines).

Knowledge translation2 is defined as the exchange, synthesis and ethically sound application of knowledge-within a complex system of interactions among researchers and users-to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system.




[1] Guus Schrijvers. Disease management: a proposal for a new definition. Int J Integr Care. 2009 Jan-Mar; 9: e06. Published online 12 March 2009.

[2] Canadian Institutes of Health Research. Knowledge translation framework. [definition (accessed 26 August, 2002)].

Disease management is a system that seeks to manage the chronic conditions of high-risk, high-cost patients as a group. The CDM Quality Care will help guiding you in a practical way that you can be successful.