Support for
Chronic Disease Patients
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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Comprehensive clinical management such as medication optimization, diagnostic test ordering, and inhaler-use coaching.
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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.
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Care coordination through personalized care plans, follow-ups, and referrals to community resources that address daily living, recreation, food, and housing needs.
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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?
OR:
NYTHP Chronic Disease Management (CDM) Hub
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 will be closed on November 11, 2025.
The clinic is by appointment-only.
If you have any questions, contact the team by:
Phone: (437) 562-3847
Email: cdmhub@nygh.on.ca
Fax: 1 (833) 665-5140
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