Chronic Disease Management Program

CDMC Picture 1

We believe that living with a long-term condition like diabetes or high blood pressure should not stop you from living your life. That is why the Chronic Disease Management Program (CDMP) is a core part of what we do.

 

The goal of CDMP is to move from being reactive to being proactive. Through group education sessions and one-on-one support for regular monitoring, we give you the tools and confidence to self-manage your health at home. By staying ahead of these conditions together, we can prevent complications and keep you feeling your best as you age. It is not just about medical treatment; it is about empowering you with the knowledge to stay healthy.

 

Multidisciplinary Approach

The CDMP is delivered through a multidisciplinary team of healthcare professionals working collaboratively to provide comprehensive and coordinated care. This team may include nurse practitioners, physicians, registered nurses, dietitians, physiotherapists, and social workers. Each discipline contributes its expertise to address not only medical needs, but also lifestyle, mental health, and social factors that influence health. Through effective communication and care coordination, the team ensures continuity of care and delivers holistic, culturally appropriate, and patient-centered services tailored to individual needs.

PROGRAMS

Background

Life can present unexpected challenges, especially for our cherished older adults and those recovering from a hospital stay or experiencing a recent decline in functional abilities. The Assess and Restore (A&R) Program is here to turn these challenges into opportunities for better quality of life and renewed independence.

Program Description

Our A&R Program is a dynamic and engaging 12-week journey designed to help you regain strength, mobility, and confidence. Here’s what you can expect:

  • Group Exercise Sessions
    • Aimed at improving your physical strength, overall health, making daily tasks easier and more enjoyable.
  • Educational Workshops
    • Topics include: Transfer training, safe use of assistive devices, falls prevention, home safety tips and strategies, healthy lifestyle, medication safety, etc.
  • Social Prescribing Activities
    • Link to community resources and social support groups to build helpful connections.

We accept post-hospital discharge referrals and community referrals. Please contact your primary care provider, hospital discharge planner, or specialist to complete the referral form. Self-referrals are also accepted.

  • Eligibility
    • Adults aged 55 or above, and either one of the following:
    • Recovering from a recent hospital stay (within 6 months), OR
    • Experiencing decline in physical and/or functional abilities
  • Schedule
    • Tuesdays and Thursdays, 1-4pm
  • Language
    • Service will be conducted in English, interpretation available in Cantonese and Mandarin
  • Cost
    • Free of Charge

We accept post-hospital discharge referrals and community referrals. Please contact your primary care provider, hospital discharge planner, or specialist to complete the referral form. Self-referrals are also accepted.

Click HERE for referral form
Background

Many cancers can develop without symptoms in the early stages. Regular cancer screening helps detect cancer earlier when treatment is more effective and survival outcomes are better.

Program Description

The Cancer Screening Program provides breast, cervical, and colorectal screenings in alignment with 2025 Cancer Care Ontario guidelines.

We have organized a series of community education workshops to promote the importance of cancer screening:

  • Multilingual education workshops provided by multidisciplinary team professionals
  • Topics include:
    • Cervical Cancer
    • Breast Cancer
    • Colorectal Cancer
Mobile Screening Clinic

Female-led HPV screening clinic

  • Every Monday from 10:00 am to 4:00 pm
  • Venue: 105 Gibson Centre
  • Accepting both self-referrals and provider referrals
  • For online booking of Mobile Screening clinic, please click HERE.

To join the program, please click the “Register Now” button below.

If you have any questions, you may call 416-502-3790 or email cdmp@carefirstontario.ca.

Ontario Health Cancer Risk Screening: https://www.mycanceriq.ca/

Cervical Cancer:

Breast Cancer:

Colorectal Cancer

Background

Cardiovascular Rehab or ‘Heart’ Rehab (CVR) is a lifestyle change and exercise program to support your recovery from heart events or to prevent it for those who are at higher risk.

How does it help me?

Although it doesn’t replace medical therapy, Cardiovascular Rehab can help you:

  • Recover to your previous level of function through progressive exercise training
  • Reduce your risk of future heart events
  • Manage high blood pressure, blood sugar, cholesterol, stress, and weight
  • Build a social circle of people with similar concerns as you
  • Connect to other services that you may need
What does it involve?

The Carefirst program is a 25 week program, where we meet once a week for 1.5 hours. Each class involves group education/discussions and group exercises (aerobic, resistance, and stretching). Our goal will be to support you with Self-Management that focuses on helping you make changes for a healthy lifestyle and build a home exercise habit.

Who can benefit from this program?

Our program is primarily designed for patients with coronary artery disease (such as heart attack) and diabetes, however you may benefit if you have any of the following:

If you had any of the following:

  • Heart attack or angina
  • Heart Surgery (Angioplasty, Stent, bypass surgery, valve replacement or repair)
  • Minor Non-Disabling Stroke

If you have any of these risk factors:

  • High cholesterol, blood pressure, weight
  • Diabetes
  • Inactive Lifestyle
How much does it cost?

There is a $80 Program Fee + additional Community Center membership fee (location dependent).

The Program fee is Non-Refundable and must be paid by the 3rd class. Please speak with a member of the program if cost is a barrier to accessing the program.

How do I enroll in the program?

Please ask your Primary Care Provider or Heart Specialist to fill out an OCEAN Referral (preferred). If your provider is not an OCEAN user, please use the following referral form on our website. *Submitting forms not using OCEAN may result in delays in processing.

Referral Form

Click HERE for referral form

The referral form ABOVE should only be used if Ocean is not available.

To send e-Referrals via OCEAN, if you are already an Ocean user, please add this listing to your Favourites on your Ocean Healthmap: Click Here

If you are not already an Ocean user, you may reach our clinician referral form on our website program page, at this link: Click Here

Community Cardiovascular Prevention Rehabilitation Program Flyer:  https://carefirstontario.ca/wp-content/uploads/2025/07/CVR-One-Pager.pdf

BACKGROUND

Funded by Ontario Health Toronto and Ontario Health Central, this free program is designed for seniors aged 65+ to support them in staying active, healthy, and mobile through regular exercise.

PROGRAM DESCRIPTION

1) Gentle Fitness – Beginner & Habit Building

  • Muscle Strengthening: simple exercises to build strength safely
  • Stretching & Balance: gentle movements to improve flexibility and stability

2) Cardio & Strength Exercise – For Active Participants

  • Cardiovascular Training: boost heart health and stamina
  • Full-Body Strength & Endurance: exercises to strengthen muscles and maintain fitness

3) Falls Prevention – For those needing extra support

  • Balance & Strength Training: improve stability and reduce fall risk
  • Lower Body Endurance: strengthen legs for safer walking and mobility

4) Cognitive Training – For Brain Health

  • Hand-Brain Coordination: exercises to enhance coordination and focus
  • Reaction & Attention Training: activities to maintain alertness and mental agility

5) Other Classes

  • Qigong Practice | Tai Cho Practice | Line Dancerise
PROGRAM NOTES:

Classes run year-round and are 50 minutes per session.

Programs are offered in group settings at various community locations, including retirement homes, seniors’ housing, and private condominiums. Virtual classes are also available.

This is not a drop-in program—registration is required.

Participants are encouraged to exercise at their own pace and to wear comfortable clothing

How to Apply

If you would like to refer yourself or someone else to this program, please call 416-847-8939 or use the link below to book an appointment with our Intake Department.

https://search.caredove.com/org/service/30836/request

Information & Enquiry

Call: (416) 847-8939

Email: wellness@carefirstontario.ca

BACKGROUND

Our program provides current, practical, culturally-relevant and customized diabetes education to help patients make decisions which will improve their blood glucose control. The program consists of multidisciplinary professional (Nurse, Dietitian, Social worker, Chiropodist, Optometrist).

Program Description

The DEP is suitable for individuals with Type 2 diabetes, poor control of diabetes or those at risk for developing diabetes (prediabetes)

  • Focus on patient’s self-management and skills enhancement
  • Customized to individual needs. Individual counselling sessions with nurse, dietitian and social worker
  • Group sessions with peer support
  • Multidisciplinary team approach
  • Feedback to patient’s own physician
  • Follow up monitoring

How to Apply for the Diabetes Education Program (DEP):

If you have type 2 diabetes or are at risk of developing diabetes and would like to join the Diabetes Education Program, please ask your family doctor to fill out and fax us the DEP Referral Form below at (905) 695-0826.

DEP Referral Form – Doctor Referral

DEP Referral Form – Self-Referral

Upcoming Events & Calendar

  • DEP group sessions will be held online through Zoom and is open to the public
  • For more information, or if you want to register for a group session, please call (905) 695-1140 or (416) 847-0283

Calendar link:  https://carefirstontario.ca/medical/diabetes-education-program-dep/#1639421277349-e1aa55f8-2e84

Background

Most people know that eating better and moving more is important, but life often gets in the way, making it hard to start or stay consistent.

Program Description

The “Feel Good, Live Well: A Healthy Living Series” is a free, three-week virtual program facilitated in partnership with Oak Valley Health’s Adult Diabetes Clinic.

This virtual program will help you:

  • Understand the role of mental health in healthy living
  • Promote and build knowledge on mindful and SMART healthy eating
  • Feel confident in reading food labels and shop smarter at the grocery store
  • Build self-efficacy through physical activity

Program information:

  • Speakers: Multidisciplinary team—including dietitian, social worker, and physiotherapist
  • 3 weekly sessions
  • Upcoming September Series: September 3, 10 & 17, 2026
  • Time: 6:00PM to 8:00PM
  • Mode: Virtual
  • Registration deadline: Aug 31, 2026

To join the program, please click the following link below and fill in the online form. For enquiries or more information, please call (905) 472-7527 (Ext. 1).

Feel Good, Live Well: A Healthy Living Series [FREE]

Background

Chronic hepatitis B can silently damage the liver for many years and may lead to cirrhosis or liver cancer if untreated. Early screening, monitoring, and appropriate treatment help protect long-term liver health and prevent complications.

Program Description

Our mission:

  • Enhance public awareness of the significance of screening and prevention of Hepatitis B
  • Empower chronic hepatitis B carriers and their family members on self-management including lifestyle management, life-long surveillance and preventive measures
  • Ensure long-term adherence to liver cancer prevention

Education Workshop:

  • Target participants: For those who are interested in knowing more about Hepatitis B
  • 1-hour virtual workshop
  • Workshop content:
    • Introduction of Hepatitis B
    • Universal Screening
    • Preventive Measures and Immunization

To join the program, please click the “Register Now” button below.

If you have any questions, you may call 416-502-3790 or email cdmp@carefirstontario.ca.

Hepatitis B Fact Sheet (English): Living with Hepatitis B Fact Sheet

Hepatitis B Fact Sheet (Chinese): Living with Hepatitis B Fact Sheet

Government of Canada:  Hepatitis B – Get the Facts – Canada.ca

Background

Osteoarthritis is a common joint condition that affects many older adults, especially in the hips and knees. It occurs when the protective cartilage in the joints gradually wears down, leading to pain, stiffness, and difficulty with movement. These symptoms can make everyday activities such as walking, climbing stairs, or getting up from a chair more challenging. Without proper management, joint pain may limit physical activity and reduce quality of life. Education, exercise, and supportive care can help seniors manage symptoms, maintain mobility, and stay active.

Program Description

Targeted for individuals diagnosed with hip or knee osteoarthritis

If you are diagnosed with hip or knee osteoarthritis, you can join the Hip & Knee Osteoarthritis Exercise & Education Program through referral by doctors or nurse practitioners.

  • Speakers: Multidisciplinary team – Physiotherapist and guest speakers (including dietitian, nurse, social worker)
  • Format: 6 weekly group sessions + 6-week independent exercise + Week 12 follow-up
  • Upcoming Series: July 10, 2026 – August 14, 2026 (Weekly on Fri)
  • Time: 2:00 pm-3:15 pm
  • Mode: In-person (optional virtual check-ins)
  • Registration Deadline: June 30, 2026

Enrollment Information:

  • This program is currently only available to patients registered with the Carefirst Family Health Team.
  • Eligible patients may be referred by their family doctor, nurse practitioner or other interprofessional team members, or may self-refer to the program.
  • All referrals will be reviewed by the program team, and appropriate candidates will be contacted to complete an initial assessment prior to starting the program.
Background

Hypertension is often called “silent killer” because it rarely presents with noticeable symptoms such as headaches or dizziness. As a result, many individuals remain unaware of the damage occurring inside their bodies until it manifests as a crisis. When left untreated, persistently high blood pressure can cause irreversible harm to major organs. It significantly increases the risk of stroke and dementia, heart attack or heart failure, chronic kidney disease leading to dialysis, and even permanent vision loss.

Program Description

To combat these risks, the Heart Smart Hypertension Education Program:

  • 3-hour workshop delivered by nurse practitioners, nurses, physiotherapists, dietitians and social workers
  • Program components include
    • Home blood pressure monitoring
    • Medication adherence
    • Exercise
    • Stress management
    • Diet modifications
  • Target participants:
    • Clients with blood pressure > 130/80mmHg
    • Carers of person with hypertension
    • Individuals who are interested to know more about hypertension
    • Language: Cantonese/ Mandarin/ English

To join the program, please click the “Register Now” button below.

If you have any questions, you may call 416-502-3790 or email cdmp@carefirstontario.ca.

Background

Carefirst Family Health Team provides comprehensive mental health and social work services, offering high-quality, accessible counseling and case management to support patients with mental health conditions or stress issues.

Our Service Navigation Services:

  • Act as a critical bridge between patients and fragmented care systems
  • Provide coordinated, person-centered assistance to access health, social, financial, and community-based resources
  • Conduct individualized assessments and follow-ups
  • Empower clients and caregivers to complete necessary applications
  • Assist clients to successfully connect with both internal and external services
Background

Smoking can have serious effects on health, especially for older adults living with chronic conditions. It increases the risk of heart disease, stroke, lung disease, and many types of cancer. Smoking can also worsen chronic conditions such as diabetes, high blood pressure and reduce lung function. The good news is that quitting smoking brings health benefits at any stage of life.

Program Description

Carefirst Family Health Team will be holding a virtual/in-person group session on smoking cessation. This session will be open to all clients and community members

It is free of cost, come join us!

What You will Learn:

  • Risks of smoking
  • Benefits of quitting
  • Tips to quit smoking
  • Tobacco screening and assessment
  • Nicotine Replacement Therapy(NRT)
  • Abrupt cessation vs. reduce to quit
  • Introduction of smoking cessation program and structure
  • Community resources

For any inquiry regarding this group session, please call 905-695-1133.

For online registration, please click the following link:

Health and Wellbeing – Carefirst

Background

Excess weight gain increases the risk of many chronic diseases such as diabetes, heart disease, and joint problems which impact overall physical and mental health, and quality of life.

Program Description
  • Aim: to facilitate sustainable weight loss through integrated lifestyle modification and clinical oversight
  • 2-day 2-hour group-based educational sessions
  • Conducted by a collaborative team of nurses, dietitians, social workers, and physiotherapists
  • Target participants: Individuals with a BMI greater than 25
  • Language: Cantonese/ Mandarin/ English

To join the program, please click the “Register Now” button below.

If you have any questions, you may call 416-502-3790 or email cdmp@carefirstontario.ca.

Information & Enquiries:

Tel: (416) 502-3790
Email: cdmp@carefirstontario.ca