Program Referral Criteria
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Dietitian consultation
- Chronic disease or conditions such as Hypertension, Dyslipidemia, obesity, CHF/stroke
- Healthy eating advice/ IBS /Digestive disorders/Celiac disease/gall stones/fatty liver
- Vitamin K/INR
- PCOS/Prediabetes
- Kidney disease stage 1&2
- Food insecurity
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Smoking Cessation (One to One Session)
- Smokers who would like to quit and those who wish to remain smoke free
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Insomnia
- Moderate to severe insomnia
Chronic Disease Management
- 2 or more chronic diseases i.e.: HTN, CHF, OA, Dyslipidemia, Dementia, CRF
- At least 3 indicators of Frailty: weakness, fatigue, weight loss/malnutrition, decreased physical activity, poor balance, visual impairment, cognitive impairment, falls
- 3 or more ER visits in past 6 months
- Polypharmacy/complex medication regime
- Presence of a life-limiting illness (non-cancerous)
- Early identification of palliative disease
- Seniors >=55 years old
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Seniors at risk
- Seniors with co-morbidities, dementia, falls, isolated seniors, living alone, recent immigrants, osteoporosis, weight loss, recurrent infection , functional decline affecting ADLs and ADLs and safety issues , caregiver having difficulty coping, community resource linkage
- Mental health and/or psychosocial issues, crisis or any major events that affects individual’s ability to manage their activities at home
- Recent repeated ED or hospital admission (<30 days) that may benefit from specialized out-patient follow up
COPD/Lung Health Program
Eligibility Criteria (must meet one of following): If smoker/ex-smoker, over 40 and “yes” to:
-
EITHER
- Persistent SOB at rest or exertion
- Activity limitation
- Persistent productive cough
- Regular respiratory tract infections
- ***admitted to hospital with COPD exacerbation
-
OR
- Cough regularly
- Cough up phlegm regularly
- Wheeze up exerting yourself at night
- get frequent colds that last longer than most
- Regular respiratory tract infections
- even simple chores make you SOB
- Mild to moderate mental health conditions
- Individual counselling or/and group programs needed.
- Does not require case management support
- System Navigation to find community or government resources and community services.
- Group therapy is contraindicated for patients with active suicide ideation or psychosis, active substance abuse, and individuals with discomfort in a group setting.
Palliative Program
- Presence of a progressive life limiting illness (cancer or non-cancer)
- Prognosis or PPS 50% or less
- Requires palliative pain and symptom management