Safety of care

Improving patient safety and reducing risks

Caring for patients with chronic diseases

Originally published April 2015

Chronic diseases are affecting increasing numbers of patients. As they are among the most common, costly, and complex medical conditions, chronic illnesses place a heavy burden on patients, their families, and society, and present treatment challenges for physicians. Practising safe medical care can help improve overall outcomes for those suffering from chronic diseases and reduce physicians’ exposure to medico-legal risks.

Avoiding or delaying costly complications in the prevention and management of chronic diseases requires a broad skill set, a proactive approach to care delivery, and a patient-centred approach.1

Chronic disease management strategies

Focusing on health promotion, disease prevention, and early detection is an optimal strategy for successful chronic disease management. Physicians can help patients understand and take responsibility for some of the underlying clinical risk factors seen in a range of chronic diseases. The Canadian Medical Association’s Policy Statement, The Role of Physicians in Prevention and Health Promotion, states that physicians should incorporate all levels of health promotion and disease prevention into their practices.2

A patient-centred approach is valuable when caring for patients with chronic diseases. Physicians should advise patients of the prognosis of their illness, how the illness can impact their lifestyle, and suggest solutions to cope with changes at work and at home. Patient adherence to investigation and treatment plans can sometimes be difficult to achieve. Physicians should take steps to educate patients about their disease, encourage proper self-care, and reinforce key messages about the health condition, as appropriate. When reasonable alternatives are available, physicians should avoid making assumptions about what treatments patients will select but rather discuss these options with patients. Patient consent remains paramount during this entire process. Doctors should also recognize when patients (e.g. some new immigrants or elderly persons) may need more help to manage their health.

Because harm can arise from poorly controlled health conditions, and because patients may be suffering from multiple diseases simultaneously, careful attention may be required when caring for patients suffering from chronic diseases. For example, it may be necessary to carefully watch for interactions among medical conditions and interactions among treatments including medications.

Cultural influences can also impact patients’ self-care and chronic disease management. For example, a patient’s or family’s attitudes towards food, weight, and exercise can impede or encourage the necessary changes in an individual patient’s approach to self-care. Physicians will need to help patients feel empowered to take responsibility for their health.

Chronic disease sufferers also need to know when they should access healthcare services and whom to contact. Physicians and patients should create an action plan including the symptoms that merit a doctor’s visit, follow-up protocols, a list of required tests, how to manage medications, and information patients should track to assist the healthcare providers in monitoring their condition (e.g. blood sugar levels, weight, blood pressure).

Care coordination

As physicians work collaboratively with other healthcare providers, it is important to coordinate care for patients with chronic diseases. Comprehensive assessment and goal-based care planning are significant components of the treatment plan. Patient care coordination is enhanced by sharing information appropriately, collaborating with other healthcare professionals, as well as preparing effective referrals and consultations. Different providers may vary in their therapeutic goals and this speaks to the need for good communications amongst providers.3

Physicians should also have measures in place to ensure all members of their practice know their roles and responsibilities. These can include assisting with care coordination, clear documentation, proper information transfer, efficient test results management, and comprehensive follow-up procedures.

Mitigating the risks

Caring for patients who suffer from chronic diseases can be challenging. However, physicians can take steps to mitigate the medico-legal risks associated with this care:

  • Emphasize health promotion and disease prevention activities with patients. Physicians should consider available resources and tools to help educate patients so they can make informed decisions and be engaged in their own care, for example telling patients about support groups for those with the same condition.
  • Be familiar with any relevant clinical practice guidelines provided by appropriate specialty societies.
  • Work with patients and other healthcare providers to develop comprehensive, patient-centred care plans. Patients should be involved in their care and take part in treatment decisions whenever possible.
  • Consider the role of electronic medical records and electronic communication. As technology advances, when feasible, physicians may opt to monitor chronic disease patients remotely and have patients involved in managing their health.
  • Help patients access care when they need it. Practice management procedures and booking systems should support patients to see their doctor or another member of the care team, when needed. Consider including a process to help with timely follow-up and missed appointments. Written follow-up and discharge instructions are helpful.
  • Communicate effectively and consistently with patients and other healthcare providers, where appropriate.
  • Document patient discussions, treatment decisions, and agreed upon responsibilities.
  • Manage test results and coordinate care cautiously. In a collaborative care setting, roles and responsibilities of the various health care providers should be clarified. The most responsible physician generally has overall accountability for directing and coordinating the care and management of an individual patient at a specific point in time.
  • Evaluate patient outcomes regularly, with the involvement of the patient.

Physicians with questions

As a member of the CMPA, physicians have access to medico-legal resources and advice. Feel free to contact a CMPA medical officer to discuss particular concerns or questions.




  1. Health Canada, “Chronic Disease Prevention and Management” 2006. Retrieved on November 21 2014 from:
  2. The Canadian Medical Association, CMA Policy, ”The Role of Physicians in Prevention and Health Promotion” (Update 2001). Retrieved on November 21, 2014 from:
  3. Ontario Medical Association, “Chronic Disease Management” 2009. Retrieved on November 21 2014 from:

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.