Chronic Disease Management

The multidisciplinary team, including a family nurse and/or pharmacist, will provide planned visits, coordinated care, counseling, and follow-up for patients with chronic illness and complex care. 

Chronic diseases are conditions that are rarely if ever cured, and therefore must be correctly managed to ensure they do not worsen. These conditions can have an impact on the physical, mental, and emotional health of patients making daily management routines difficult to follow.  

Therefore, it is important that patients with chronic diseases fully understand their disease and have the resources and supports to manage it correctly. Patients must take actions to maintain health at home, between visits with health professionals. This can include actions such as staying active, eating healthy, and following medical instructions. 

In order to make these things easier for patients, the PCN can provide information to patients about their disease as well as assistance in dealing with disease management strategies. ​ 


This service is currently offered at these PCN locations: Tofield, Vegreville, Vermilion, Viking, Hardisty, Killam


A PCN Nurse can provide an ankle-brachial index (ABI) as a quick noninvasive way to check your risk of peripheral artery diease.
The PCN multidisciplinary team will provide coordinated care for patients with diabetes.
A PCN Nurse provides foot care services for patients with diabetes or other foot care issues.
Learn about what lifestyle and medical choices you can make to better mange your blood pressure.
The weight management program, provided by a clinic nurse or dietician, will help you learn to make healthy lifestyle choices, starting with your mindset, nutrition, and activity.