Chronic Disease Management Program

CDMC Picture 1

Established in 2011, Carefirst’s Chronic Disease Management Centre (CDMC) is a group of services to help ‘You help Yourself’ by supporting you to acquire the right knowledge, resources and skills.

Our mandate is to:

  • Empower adults who are living with or at risk of chronic diseases
  • Support caregivers of individuals living with chronic conditions
  • Collaborate with other community health care providers to ensure that the holistic needs of individuals are addressed

 

CDMC will collaborate with each person to build a plan to meet your unique needs and preferences

STAFF

Our team of health professionals includes Registered Nurses, Dietitians, Physiotherapists, Social workers, Kinesiologists, Pharmacist, Social Worker, Nurse Practitioners, Occupational Therapist, and Behavioral Support Nurse collaborate with clients and caregivers to enable them to live as independently as possible in the community with an optimal quality of life.

Cardiovascular Rehabilitation

PROGRAMS

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.

What you can expect

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.

REFERRAL FORM

Click HERE for referral form

 

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 after hospitalization.
  • Schedule
    • Tuesdays and Thursdays, 1-4pm
  • Language
    • Service will be conducted in English, interpretation available in Cantonese and Mandarin
  • Cost
    • Free of Charge
  • Assess & Restore Program Brochure
  • Assess & Restore Program Flyer

The Scarborough Doctors’ Family Health Organization (FHO) is a dedicated groupof health care professionals who support clients with the following:

  • Chronic health conditions (e.g. high blood pressure, diabetes)
  • Mental health concerns (e.g. depression, anxiety)
  • Dietary issues related to chronic disease and its’ treatment (e.g. overweight, obesity)
  • Mobility and/or physical decline

What services do we offer?

Mental Health Services

Supporting individuals and families of all ages who may be facing adversity, life transitions and challenges, and emotional distress.

The following supports are available;

  • Stress management (use of Cognitive Behavioural Therapy coping techniques and strategies to manage distress)
  • Management of depression and anxiety
  • Trauma informed counselling
  • Crisis intervention
  • Grief counselling
  • Information and referral services
  • Links to community resources
  • Service coordination and navigation

Physiotherapy

To enhance and restore physical function using assessment and a broad range of therapeutic interventions and aids. They apply a collaborative and reasoned approach to help clients achieve their health goals.

These includes:

  • Managing acute and chronic conditions, activity limitations, and participation restrictions
  • Promoting optimal mobility, physical activity and overall health and wellness
  • Preventing disease, injury, and disability
  • Improving and maintaining optimal functional independence and physical performance
  • Rehabilitating injury and the effects of disease or disability with therapeutic exercise programs and other interventions
  • Educating and planning maintenance and support programs to prevent re-occurrence, re-injury or functional decline.

Dietitian

To address nutrition concerns for individuals in all stages of the life cycle, from childhood to older adults, as well as those living with chronic diseases. The objective is to promote health and prevent and manage conditions such as obesity, high blood pressure, diabetes, heart disease, and gut issues. This includes:

  • Nutritional assessment and counselling
  • Nutrition education and providing diet recommendations for clients with various nutrition concerns while collaborating with appropriate others (the client, other team members and the family physician). Information is individualized and nutrition care plans are developed according to each client’s unique lifestyle.

REFERRAL FORM

Click HERE for referral form

 

Patients of the Scarborough FHO are eligible for our services. Please ask your family physician for a referral.

  • Schedule
    • We are open Monday to Friday from 9-5pm. Evening and weekend appointments may berequested as needed.
  • Language
    • Our team speaks English and other languages to assist with communication if necessary.
  • Family Health Organization Brochure

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 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.

Geriatric Assessment and Intervention Network (GAIN) provides specialized geriatric care to support frail seniors living at home or in retirement residences, who have multiple complex medical and social problems.

Some Conditions Include:

  • Cognitive impairment
  • Responsive behaviours
  • Decreased function
  • Falls or risk of falls
  • Impaired mobility
  • Incontinence and/or
  • Multiple medications

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.

Collaboration with Carefirst Family Health Team

  • Diabetes Education Program
  • Weight Management Program
  • Osteoporosis Management Program

Location & Business Hours:

300 Silver Star Blvd., 2/F, Scarborough, ON M1V 0G2
Monday – Friday 9:00 am – 5:00 pm

 

Information & Enquiries:

Tel: (416) 847-8941
Fax: (416) 646-5111
Email: cdmc@carefirstontario.ca