Primary Care Providers Come Together to Advance Chronic Disease Prevention and Management

Health planning at the primary care level in Waterloo Wellington is changing thanks to the many area primary care providers who came together to form the Chronic Disease Prevention and Management Advisory Group. 

With more than 8,000 seniors living in Waterloo Wellington with four or more chronic conditions, the work of the group is vital and has already helped to improve the health of local residents.

“My role as the lead for Chronic Disease Prevention and Management (CDPM) is to get primary care practitioners involved in planning whatever requirements are needed, determine how to best implement those resources to support patients with chronic diseases in the community and improve their overall health and wellbeing,” explains Dr. McPhedran who helped lead the group. “Having the input, expertise and feedback from so many primary care providers and other health professionals is invaluable. Chronic illnesses don’t go away. We need to make sure that patients and their caregivers have the tools, support and education they need to manage their illness for the best quality of life as possible.”

The CDPM Advisory Group included primary care practitioners from across Waterloo Wellington as well as representation from the WWLHIN, public health, a pharmacist, Guelph Community Health Centre and Langs Community Health Centre. They helped to guide, design, and recommend strategies for an integrated system of CDPM services and analyzed system performance.

Looking at leading practice models of care, the group prioritized which models will work well for adoption and spread throughout Waterloo Wellington to best impact resident health.  One of these is the chronic heart failure program at the New Vision Family Health Team, designed to provide chronic heart failure patients with more comprehensive care through primary care, with support from hospitals when needed. The program has helped to reduce hospitalizations by 67%, decrease emergency department visits for heart-failure related issues by 44% and reduce revisits to area emergency departments within 30 days by 47% for patients with chronic heart failure.

“Any support models or initiatives we considered included the perspectives of different primary providers as well as the unique needs of residents,” says Dr. McPhedran. “That’s why the participation of so many primary care providers was so critical. Our collective hope is that primary care providers in Waterloo Wellington will have the supports they need to help their patients manage their chronic illnesses whether that be through case management, clinical supports or access to interdisciplinary teams.”

Local CDPM work will continue to move forward to improve the health of residents as plans shift to address care processes at the community level.

“Primary care plays a significant role in increasing the health of patients with chronic illness,” says McPhedran. “And we’re looking at ways to help them help their patients.”

The Waterloo Wellington LHIN would like to thank the following care providers for their participation in the CDPM Advisory Group:


Dr. David Schieck, Dr. Carol Thomson, Dr. Sean Gartner, Dr. Rebecca Guzaar, Dr. Shvan Korsheed, Dr. Linda Lee, Dr. Lois McLaughlin, Dr. Martha Taylor, Dr. Julie Wilhelm, Dr. Evgenia Oreshkin, Dr. Sabrina Lim Reinders, Dr. Meredith Barakat, Dr. Nicola Mercer and Dr. Peter McPhedran.


Gina Di Vizio

Nurse Practitioner:

JoAnn Vickers

And Debbie Hollohan, CDPM director at Langs