Program Referral Criteria

• 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
• Smoking Cessation (One to One Session)
  • Smokers who would like to quit and those who wish to remain smoke free
• 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
• 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