Programs and Services

Programs and services delivered by the London Family Health Team are geared to the population groups we serve focusing on chronic disease management, disease prevention and health promotion.

Chronic diseases are long-term diseases that develop slowly over time, often progressing in severity, and can often be controlled, but rarely cured. They include conditions such as cardiovascular diseases (heart disease and stroke), cancer, diabetes, arthritis, back problems, asthma, and chronic depression. Chronic diseases may significantly impair everyday physical and mental functions and reduce one’s ability to perform activities of daily living. Although chronic diseases are among the most common and costly health problems facing Canadians, they are also among the most preventable.

Along with the programs and services listed below, the team also focuses on advance care planning, influenza and pneumovax vaccinations for complex patients, and cancer screening.

The aim of the Diabetes Management Program is to support patients who are living with diabetes which may be complicated by poor glycemic control or additional chronic diseases. A collaborative approach with health care professionals such as a chronic disease nurse, social worker, pharmacist, dietitian and an endocrinologist is used to better manage the disease and its complications. The team also provides patients and their caregivers with the knowledge, skills and confidence to more effectively self manage their diabetes with targeted and effective strategies.

The Complex Chronic Disease Management Program supports patients who suffer from four or more chronic diseases which may include but are not limited to, kidney failure, heart disease, COPD, dementia or mental illness.  The interprofessional collaborative team approach coupled with a patient centred focus, integrates self management goals to maximize the effectiveness of medications, diet, exercise and other lifestyle changes.

The London Family Health Team’s social workers work to improve and standardize the identification (screening and assessment) and treatment / lifestyle management of patients with chronic depression. The team also works with all patients diagnosed with mental health concerns including anxiety or requires acute situational crisis counseling. Patients can be referred through their London Family Health Team family physician or if you are a patient of one of our physicians, you can self-refer. If you are self-referring, please contact the receptionist at the London Family Health Team by calling 519-471-8506.

The London Family Health Team’s Mental Health Program includes the expertise of a psychologist who works with young children and adolescents aged 2-18 years to  identify, screen and assess ADHD and related mental health conditions. The program uses a collaborative approach that involves the patient, family and interdisciplinary professionals that addresses treatment adherence as well as how to cope with the challenges of the diagnosis.

The London Family Health Team dietitian provides nutrition screening and counselling to patients in need of nutrition, education, management and support. The service aims to help patients achieve optimal health outcomes through reducing disease complication and empowering patients to self manage.

The London Family Health Team pharmacist provides support to family physicians and patients to ensure drug safety, optimize drug therapy and improve therapeutic outcomes. The pharmacist identifies discrepancies/medication related programs, creates a complete and accurate inventory of all medications and provides education to patients in all aspects of medication use including polypharmacy counselling, compliance packaging, high risk medications, medication options and options for drug funding.

Upon discharge from hospital, patients are referred to the London Family Health Team pharmacist for a review of medications to ensure records are accurate and up to date to optimize safe, effective and appropriate drug therapy.

Through early detection and better management, the Lung Health Management Program aims to improve the health outcomes and quality of life for patients at risk for respiratory diseases and those who have been diagnosed with COPD (Chronic Obstructive Pulmonary Disease) and Asthma.

The aim of the Geriatric and Frail Elderly Program is to ensure optimum health and quality of life for geriatric and frail patients living with multiple chronic conditions. The program works to strike a balance between clinical guidance, healthcare needs and patient preferences as well as to improve access to health care by providing home visits when necessary.

The Smoking Cessation Service supports patients with counselling and medication management to meet their goal of quitting smoking.

The London Family Health Team supports Ontario’s Cancer Screening Program by helping to ensure patients are up to date with their cancer screening and to provide information and education.