Chronic Disease/NCD Collaborative & CDEMS

Patrick S Luces & Augusta Rengiil

Pacific Chronic Disease Council

Why we need this model?

• Regional Assessments• Lack collaboration between medical care providers and public

health staff• Lack of system of clinical services to assure continuity of care• Lack up-to-date policies and procedures• Lack of standards of care• Lack of consistent data

• FASC Recommendations listed (April 2009)• Data• Certified NCD lifestyle educators• NCD Collaborative

What is a collaborative?

The Collaborative approach involves improvements in six elements of NCD team care: • Self-management• Decision support• Clinical information system (CDEMS)• Delivery system design• Organization of health care• Community

What is CDEMS? CDEMS: Chronic Disease Electronic Management

System is a flexible database to help document and track

health care outcomes. is designed to assist medical providers and healthcare

management and tracking and improving the care of patients with one or more chronic health conditions.

allows both patient level tracking/reporting and population level tracking/reporting.

Meeting your needs..

• CDEMS can easily be adapted to the unique needs of the USAPI (i.e. betel nut and sakau use) can be added as behavioral risks. • Easily modify or change any clinic/hospital

reports, formatting of Progress Notes, or any field in the program.

Thank You!