Chronic Disease Prevention and
Management (CDM) Community Hub

• The Chronic Disease Prevention and Management (CDM) Community Hub is a free clinic that provides easy access to care for people who are living with specific chronic health diseases (congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD)), as well as those at higher risk for these diseases.

• Our goal is to help you manage or prevent chronic disease by understanding your physical, social, and mental wellbeing to develop a personalized coordinated care plan and connect you to appropriate resources that are convenient for you to access.

• We know it can be overwhelming to find the right help when you are living with or are at risk of a chronic disease. The CDM Community Hub provides you with easy access to a free clinic near you and an interdisciplinary team of health care professionals who can help you navigate your care journey and develop a personalized coordinated care plan that considers your physical, mental and social wellbeing.

• We have language translation support available for those who need it. We also provide support with navigating the healthcare system and can connect you to local resources for additional assistance with employment, housing, nutrition, transportation and more.

• If you are at risk for or living with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD), the CDM Community Hub can help connect you to appropriate care.

• You can still access resources and supports at the CDM Community Hub even if you do not have a primary care provider (family doctor or nurse practitioner) or access to health insurance programs (e.g., OHIP).

• If you do have a primary care provider (family doctor or nurse practitioner), the CDM Community Hub is designed to work with them to coordinate your care and attending our clinic will not impact your standing with your provider.

We are an interdisciplinary team of health care providers and professionals, including:

• Medical Administrator: The medical administrator is your first point of contact and helps manage your medical records and coordinate your appointments.

• Registered Nurse: Registered Nurses (RNs) provide direct care to patients, deliver health education programs and support clients in managing their own health.

• Nurse Practitioner: Nurse Practitioners (NPs) are registered nurses with advanced training and clinical experience who can diagnose and treat illnesses, order and review tests, prescribe medication and perform medical procedures. They can advise on physical and mental health supports and work closely with other providers for a whole-person approach to care.

• Care Navigator (Social Worker): A care navigator is a trained professional, such as a social worker, who can help guide you through the healthcare system and connect you with social services. They may coordinate services and address a variety of your physical, social and practical needs.

The CDM Community Hub is a free clinic available by appointment only, at 5 Fairview Mall Drive, Suite 359. Appointments times are between 9:30 am - 3:00 pm and appointments are approximately 1 hour long. See a list of our upcoming clinics below.

There are two ways you can register for the CDM Community Hub.

1. Self-Referral: Complete our online pre-registration form to express interest in attending our CDM Community Hub. Our team will contact you to collect basic medical information and to schedule your appointment.

2. Provider Referrals: You can also be referred by your primary care provider or express your interest at one of NYTHP OHT’s Community Health and Information Fairs (CHIFs).

If you need assistance with the online pre-registration form or require language support, please connect with a Community Health Ambassador or call the North York Seniors Hotline at 416-447-5200.

• Before Your Appointment: Our Medical Administrator and the Registered Nurse (RN) will contact you before your appointment to learn about you and your medical history, and to confirm your appointment time and location. This helps us tailor your upcoming appointment to ensure we are well prepared to address your needs and concerns.

• Your Appointment: During your appointment (approximately one-hour), you will meet with the CDM Hub team, including a Medical Administrator, Registered Nurse (RN), Nurse Practitioner (NP), and Care Navigator (Social Worker). At this appointment, we will collect measurements, discuss any supports you need, and see how we can help.

• After Your Appointment: You will receive at least two follow-up calls from our Care Navigator (Social Worker) and Nurse Practitioner (NP) to see how you are doing and ensure you are getting connected to the services we have referred you to. The Care Navigator and Nurse Practitioner (NP) will schedule your first follow up call approximately two weeks after your initial appointment to check in, see how your goals are progressing, and discuss any challenges you are facing. They will then schedule your next follow-up call to help you with additional assistance if needed and continue supporting you on your journey. You will receive a personalized Coordinated Care Plan that will be tailored to your physical, mental, and social needs. It will also include guidance and direction on next steps for managing your condition or prevention strategies.