COD 5: Providing ongoing management for patients with chronic conditions

Key Features

  • This EPA focuses on providing ongoing comprehensive management that includes implementing screening, surveillance, or monitoring strategies, assessing medication adherence and effects, as well as addressing patient and family concerns, and providing education and appropriate follow-up.
  • It includes identifying patients with a fluctuating clinical course, recognizing the need for change or escalation of therapy, and implementing a therapeutic plan.
  • This EPA may include patients whose condition is complex, and therefore requires a consideration of the patient’s treatment goals, interactions between different diseases and treatments, consideration of multimorbidity and frailty and, often, coordination with other physicians and health care professionals.
  • This EPA includes providing anticipatory guidance to the patient and family in the primary care role for overall health maintenance and/or surveillance, and advocating for the patient’s health care needs.
  • This may include the management of patients who are technology dependent.

Assessment plan

Direct observation or case review by supervisor

Use form 1. Form collects information on:

  • Observation: direct; case review
  • Type of condition: respiratory; gastrointestinal; ID; cardiac; rheumatic/musculoskeletal; hematology/oncology; endocrine; neurology; renal/genitourinary; otolaryngology/ophthalmology; dermatology; genetic; allergy/immunology
  • Setting: inpatient; outpatient; emergency department; community; NICU; PICU; home

Collect 8 observations of achievement

  • At least 3 direct observations
  • At least 8 different conditions
  • At least 1 community setting
  • At least 5 different observers

CanMEDS milestones

  1. ME 1.4 Perform a clinical assessment that address all relevant issues
  2. ME 2.1 Consider comorbidities and clinical urgency in determining priorities to be addressed
  3. ME 2.2 Select and/or interpret appropriate investigations
  4. ME 2.2 Integrate and summarize information obtained through the clinical assessment and investigations
  5. ME 2.4 Identify and address interactions between different diseases and different treatments
  6. ME 2.4 Develop and implement a management plan that considers all of the patient’s health problems and context
  7. ME 2.4 Adapt guideline-based recommendations for care to the context of the patient’s specific needs and priorities
  8. ME 4.1 Determine the need for and timing of referral to another health care professional
  9. ME 4.1 Establish plans for ongoing care, follow-up on investigations, response to treatment and/or monitoring for disease progression
  10. COM 5.1 Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions
  11. COL 1.2 Work effectively with other health care professionals, including other physicians
  12. L 2.1 Demonstrate resource stewardship in clinical care
  13. HA 1.1 Facilitate timely access to services and resources in the health or social system(s)
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