ਸਰੋਤ
If you’re supporting patients with COPD and/or CHF, especially those recently diagnosed or post-hospital discharge, the NYTHP Chronic Disease Management (CDM) Hub is here to help.
By referring to the CDM Hub, your patients gain access to:
Clinical support provided by a team that includes a Registered Nurse, Nurse Practitioner, and Social Worker.
Services may include:
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Medication optimization, diagnostic test ordering, and ongoing monitoring.
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Education and coaching on disease management, behaviour change, and treatment plans.
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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).
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Social support and system navigation, including access to income or housing services, and drug coverage advocacy.
ਸਿਹਤ ਸੰਭਾਲ ਪ੍ਰਦਾਤਾ ਲਈ ਸਰੋਤ
The CDM Hub offers a primary care team-based approach, providing patients with coordinated support that aligns with provincial Quality Standards.
We focus on patients who need extra time, education, coaching, and system navigation, particularly those cared for in solo primary care practices or seeking attachment.
You remain the primary care provider, and our team will share timely, helpful updates to support your care planning (without overwhelming your inbox).
Please note we do not accept patients with acute exacerbation or who require rapid-response care.
Clinic details:
East North York
Flemingdon Health Centre (Fairview Site)
5 Fairview Mall Drive, Suite 359
North York, M2J 2Z1
Tuesdays and Fridays from 9:00 a.m. to 4:00 p.m.
The clinic is by appointment-only.
Contact the team at (437) 562-3847 or email cdmhub@nygh.on.ca if you have any questions.
How to refer
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Fax a completed referral form to us at 1-833-665-5140
OR
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Have your patient fill out a self-referral form at www.northyorkcdmhub.ca