Support for Chronic Disease Patients

Ресурсы

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:

Comprehensive clinical management such as medication optimization, diagnostic test ordering, and inhaler-use coaching.
Education, counselling, and coaching to support behaviour change and chronic disease management (COPD, CHF), including nutrition guidance, smoking-cessation strategies, and referrals to exercise or rehabilitation programs.
Care coordination through personalized care plans, follow-ups, and referrals to community resources that address daily living, recreation, food, and housing needs.
Social and system navigation support, including access to income or housing services, and drug coverage advocacy.

As our Hub is a free service and our clinicians do not bill OHIP, your Access Bonus will not be affected if you refer your patient. If you have questions or concerns, please feel free to reach out to Dr. Rebecca Stoller at Rebecca.Stoller@nygh.on.ca.

Ready to Refer?

Send a Referral via OceanMD

OR:

Referral Form Guide

Referral Form

Ресурсы для поставщиков медицинских услуг

Мы — бесплатная мобильная клиника в Норт-Йорке, которая обеспечивает легкий доступ к медицинской помощи людям, страдающим или подверженным риску возникновения определенных хронических заболеваний.

Для получения дополнительной информации свяжитесь с нами по адресу cdmhub@nygh.on.ca или позвоните на горячую линию для пожилых людей Северного Йорка по телефону (416) 447-5200.