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Complex Chronic Disease Management Clinic   at
Peter Lougheed Centre
Specialty: Chronic Disease
Connect Care Department: CGY PLC CCDM CL
Estimated time to routine appointment: Within 1 month
Alberta Health Services - Calgary Zone
SERVICE DESCRIPTION
The purpose of the Complex Chronic Disease Management Clinic (CCDMC)is to provide intensive management of complex medical patients to effectively decrease exacerbations and hospital presentations.Services provided may include:
  • provide family physicians and specialists with patient's plan of care within 2-3 business days of the patient's visit
  • serve as a single point of contact for both patients and family physicians to assist in navigating the health care system
  • facilitate communication between all care providers
  • the clinic aims to minimize poly-pharmacy and invasive investigation/intervention, while at the same time maximize care coordination and patient self-management
  • CCDMC does not replace the care of a family physician. The clinic will adjust medications and assist in the management of the patient's medical issues unless specifically requested not to by the family doctor or a specialist
  • patients will be discharged from the CCDMC when they are comfortable going 3 months without a clinic visit
The purpose of the Complex Chronic Disease Management Clinic (CCDMC)is to provide intensive management of complex medical patients to effectively decrease exacerbations and hospital presentations.Services provided may include:
  • provide family physicians and specialists with patient's plan of care within 2-3 business days of the patient's visit
  • serve as a single point of contact for both patients and family physicians to assist in navigating the health care system
  • facilitate communication between all care providers
  • the clinic aims to minimize poly-pharmacy and invasive investigation/intervention, while at the same time maximize care coordination and patient self-management
  • CCDMC does not replace the care of a family physician. The clinic will adjust medications and assist in the management of the patient's medical issues unless specifically requested not to by the family doctor or a specialist
  • patients will be discharged from the CCDMC when they are comfortable going 3 months without a clinic visit
ELIGIBILITY REQUIREMENTS
Two or more chronic disease conditions (i.e. COPD, dyslipidemia, CHF, HTN, Diabetes or others). Excluding patients with chronic pain. Excluding dialysis patients who have had least one emergency / inpatient visit in the past 12 months.
If you have a complex patient who does not meet the above criteria, they will be considered on an individual basis. Please contact CCDMC.
Two or more chronic disease conditions (i.e. COPD, dyslipidemia, CHF, HTN, Diabetes or others). Excluding patients with chronic pain. Excluding dialysis patients who have had least one emergency / inpatient visit in the past 12 months.
If you have a complex patient who does not meet the above criteria, they will be considered on an individual basis. Please contact CCDMC.
Referral instructions for primary care, community care, private
providers etc. who do not send referrals via Connect Care. 
REFERRAL PROCESS - FOR NON-CONNECT CARE USERS
Complete the referral form and fax it to the service using the contact information in this profile.
If urgent mark the referral as urgent, fax referral and call the referral phone number listed on this profile.
Complete the referral form and fax it to the service using the contact information in this profile.
If urgent mark the referral as urgent, fax referral and call the referral phone number listed on this profile.
REFERRAL PROCESS - FOR CONNECT CARE USERS
Send an Internal Referral using the Ambulatory Referral Order to Chronic Disease, type CGY PLC CCDM CL in the “To Department” section and complete order. 
Send an Internal Referral using the Ambulatory Referral Order to Chronic Disease, type CGY PLC CCDM CL in the “To Department” section and complete order. 
ADDITIONAL SERVICE DETAILS

The Complex Chronic Disease Management Clinic (CCDMC) is for patients who havelong-term and complex medical conditions. The purpose of the CCDMC is to decrease exacerbations of chronic conditions and acute care admissions/emergency department presentations through intensive disease management.  At the outpatient visit, the patient will be seen by Physician, Nurse Clinician, and Pharmacist.  The frequency of visits will depend on the needs of the patient. Communication between CCDMC and the patients family physician/specialists is essential to ongoing management and will be a priority to the CCDMC.  The CCDMC is not intended to replace the family physician. The intent is to work collaboratively as a team.

The clinic is staffed by a team of medical specialists including physicians, registered nurses, and pharmacists. The care they provide is carried out in close partnership with the family physician or specialists.

The purpose of the clinic is:

  • To help the patient manage long-term conditions
  • To coordinate patient care between medical specialists, family physicians and community care providers.

Any specialists actively involved in the care of the patient will receive copies of all assessments and care plans made by the clinic within 3 business days of the scheduled appointment.

 


The Complex Chronic Disease Management Clinic (CCDMC) is for patients who havelong-term and complex medical conditions. The purpose of the CCDMC is to decrease exacerbations of chronic conditions and acute care admissions/emergency department presentations through intensive disease management.  At the outpatient visit, the patient will be seen by Physician, Nurse Clinician, and Pharmacist.  The frequency of visits will depend on the needs of the patient. Communication between CCDMC and the patients family physician/specialists is essential to ongoing management and will be a priority to the CCDMC.  The CCDMC is not intended to replace the family physician. The intent is to work collaboratively as a team.

The clinic is staffed by a team of medical specialists including physicians, registered nurses, and pharmacists. The care they provide is carried out in close partnership with the family physician or specialists.

The purpose of the clinic is:

  • To help the patient manage long-term conditions
  • To coordinate patient care between medical specialists, family physicians and community care providers.

Any specialists actively involved in the care of the patient will receive copies of all assessments and care plans made by the clinic within 3 business days of the scheduled appointment.

 


COMMUNICATION PROCESS
  • Referral receipt to referring source within 7 days.
  • Acceptance via appointment details or wait list status letter to referring source and patient within 14 days.
  • Appointment outcome to referral source within 30 days.
 
PHONE
403-943-4131
FAX
403-943-4133
REFERRAL PHONE
403-943-4131
REFERRAL FAX
403-943-4133
REFERRAL FORM
CLICK + TO VIEW REFERRAL GUIDELINES
+-
Routine Reason for Referral
Access Targets convey the clinically appropriate timeframe patients should be seen within, by reason for referral and priority level.
Access Target
Required Information/Investigations
Investigation Timing
Additional Details
+-
Chronic disease
Medication List (dose, frequency, route)
 
Within 1 month
Past medical history
 
Within 1 month
Complete list of co-morbidities
 
Within 1 month
Up to date lab investigations as guided by patient's chronic diseases, ie: if diabetic, recent A1C and urine microalbumin
 
Within 1 month
Disease specific investigations as guided by patient's chronic diseases, ie: if cardiacinvolvement, provide all cardiac investigations and consultations.
 
Within 1 month
Complex Chronic Disease Management is defined as two or more chronic disease conditions (excluding chronic pain and dialysis) accompanied by at least one hospital admission and/or ED visit in the past year.
PATIENT APPOINTMENT INFORMATION
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MISSED APPOINTMENT GUIDELINES

In the event that you cannot make your appointment, please call the clinic 24hours prior to your scheduled appointment. If an appointment is missed, the patient will be contacted with an attempt to reschedule.

In the event that you cannot make your appointment, please call the clinic 24hours prior to your scheduled appointment. If an appointment is missed, the patient will be contacted with an attempt to reschedule.

 
HOURS OF OPERATION
Monday: 7:30 am - 3:30 pm
Tuesday: 7:30 am - 3:30 pm
Wednesday: 7:30 am - 3:30 pm
Thursday: 7:30 am - 3:30 pm
Friday: 7:30 am - 3:30 pm
Description:
Closed on Statutory holidays.
   
 
ADDRESS
3500 26 Avenue NE
Calgary Alberta
T1Y 6J4
PATIENT APPOINTMENT INSTRUCTIONS
  • Bring your Alberta health care card and a piece of government issued photo ID.
  • Check in at reception 15 minutes prior to your scheduled appointment time.
  • You may bring a family member or significant other during your consultation.
  • Please make sure to have someone with you if you are unable to communicate in English.
  • Bring your Alberta health care card and a piece of government issued photo ID.
  • Check in at reception 15 minutes prior to your scheduled appointment time.
  • You may bring a family member or significant other during your consultation.
  • Please make sure to have someone with you if you are unable to communicate in English.
 
DIRECTIONS
Peter Lougheed Centre site information.
Thisclinic is located within the PLC Outpatient Area (Main Floor).  The Outpatient Area is best accessed via the West Entrance of the hospital (faces the parkade).  Visitor Parking is also accessible via the West Entrance via 26th Avenue NE. Upon entering the hospital, turn right at the information desk and you will see a large sign indicating Outpatient Clinics.   Enter the clinic area and follow the signs to the reception area. 

Peter Lougheed Centre is located at the intersection of 36 Street NE and 26 Avenue NE.
Peter Lougheed Centre site information.
Thisclinic is located within the PLC Outpatient Area (Main Floor).  The Outpatient Area is best accessed via the West Entrance of the hospital (faces the parkade).  Visitor Parking is also accessible via the West Entrance via 26th Avenue NE. Upon entering the hospital, turn right at the information desk and you will see a large sign indicating Outpatient Clinics.   Enter the clinic area and follow the signs to the reception area. 

Peter Lougheed Centre is located at the intersection of 36 Street NE and 26 Avenue NE.
 
PHONE
403-943-4131
 
PARKING INSTRUCTIONS
Transit:C-train- Blue Line t (Route 202) to RUNDLE station,
Walk 1 block, north to 26 Ave to facility (5 minutes)
City transit - Calgary Transit Routes 34, 48 and 57 serve within 1 block of the facility
Route 19 and 32 lets passengers across the street on 26 Avenue NE.
Rates apply 24 hours per day, and are in effect for all public parkers, including those with provincially issued placards for persons with disabilities.
Paystations accept Canadian coins, Canadian bills or credit card (Visa, MasterCard, and American Express).
Parking Office and Kiosk accept payment by cash, credit card, debit or cheque.
Transit:C-train- Blue Line t (Route 202) to RUNDLE station,
Walk 1 block, north to 26 Ave to facility (5 minutes)
City transit - Calgary Transit Routes 34, 48 and 57 serve within 1 block of the facility
Route 19 and 32 lets passengers across the street on 26 Avenue NE.
Rates apply 24 hours per day, and are in effect for all public parkers, including those with provincially issued placards for persons with disabilities.
Paystations accept Canadian coins, Canadian bills or credit card (Visa, MasterCard, and American Express).
Parking Office and Kiosk accept payment by cash, credit card, debit or cheque.
 
EMAIL
VIRTUAL APPOINTMENT INFORMATION
 
 
WHEELCHAIR ACCESSIBILITY
Yes

On major bus route and lifts on site.


The primary purpose of the All Locations list is to let the user easily access any location of a healthcare service without going back to the main search screen.

The locations listed have 3 background colors:
  • Green means the healthcare service@location has referral information attached to it.
  • Brown means the healthcare service@location never had referral information attached to it, or it has unpublished referral information.
  • Red means
    • IA changed the healthcare service@location's status to something other than Current
    • It was deleted if it is an ARD healthcare service@location.
Green  and Brown are always at the top of the list. These are the Healthcare Service@Locations with the status of Current.
The Red list at the bottom consists of non-current Healthcare Service@locations that once had Published referral information in the ARD.
If the referral information was never published in ARD the Healthcare Service@location will not show in the Red list.

The secondary purpose of the All Locations list is to allow ARD Administrators to recover (copy) referral information from the non-current Healthcare Service@Locations to ones that are current.

Common Scenario:
A Healthcare Service moves from one location to another. In this case the IA Healthcare Service@Location record will be made defunct (non-current) and a new Healthcare Service@Location record will be created with a current status. In this scenario the captured referral guidelines in ARD can become "orphaned" as they are not attached to any current IA healthcare service.

Categories of non-current or orphaned referral guidelines: INDIVIDUAL and COMMON.
The REFERRAL GUIDELINES section of the profile has the prefix INDIVIDUAL or COMMON to help you choose the method below when transferring referral guidelines from a non-current Healthcare Service@Location to a current healthcare service@location.

Individual referral process
  1. Click on a non-current (Red) Healthcare Service@Location at the bottom of the All Locations list.
  2. The non-current referral info is displayed with the link Copy this Referral Process to another Healthcare Service@Location link on the upper right hand corner. Click on the copy link.
  3. Choose a current location (Green or Brown) from the All Locations list. This will be the Healthcare Service@Location you are pasting the referral info into.
  4. The system will display the Edit Referral Info screen populated with the referral info from the non-current Healthcare Service@Location you viewed in the first step.
  5. Click Save and the referral info is transferred from the non-current Healthcare Service@Location to the current one.
  6. Repeat these steps for each Healthcare Service@Location that needs attention.

Common referral process - 2 sub cases.
Case 1: At least 1 current Healthcare Service@Location with common referral info is with current status for this healthcare service; One or more Healthcare Healthcare Service@Locations where replaced by new one.
  1. Click on any current Healthcare Service@Location whether it has referral info (Green) or not (Brown).
  2. The healthcare service location opens in the Edit Referral Info screen populated with the current common referral info.
  3. Save it. 
  4. All locations will be updated with the common referral information, including all the locations that don't have referral info yet (Brown). The non-current referrals (Red) will also be updated.
Case 2:  All Healthcare Healthcare Service@Locations for a healthcare service are set to a non-current status and replaced by new ones. In this case there is no current additional referral info to copy from, so the only alternative is to pick up the non-current common referral process (Red). Follow the steps described in the section Individual Referral Process above to copy/paste the non-current common referral info to the current healthcare service locations.
Generally we want to replicate current common referral info to new or replaced healthcare service locations. We only resort to copying non-current common referral info if there is no other option.

Remember: Some fields can be location specific with the common referral process:
Parking Instructions, Directions, Parking Map, Wait Time, Referral Phone or Referral Fax.
To update these items you have to edit each Healthcare Service@Location separately.

ADDITONAL NOTES:
  • The info icon after the All Locations drop down will be visible to ARD Administrators.
  • The system doesn't allow you to copy referral information from one non-current Healthcare Service@Location to another.

 

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