Clinical support provided by a team that includes a Registered Nurse, Nurse Practitioner, and Social Worker.

​​

Services may include:

• Medication optimization, diagnostic test ordering, and ongoing monitoring.​

• Education and coaching on disease management, behaviour change, and treatment plans.​

• Care coordination through personalized care plans, regular follow-ups, and referrals to community resources (e.g., exercise and recreational programs) and other health-related services (e.g., smoking cessation and cardiac rehabilitation).​

• Social support and system navigation, including access to income or housing services, and drug coverage advocacy.