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.
Diabetes and Other Chronic Disease Management Program
The aim of the Diabetes and other Chronic Disease Management Program is to support patients who are living with diabetes and other chronic diseases such as kidney failure, heart disease, liver disease, COPD, mental health, etc. Patients with diabetes may experience poor blood sugar control and other additional chronic illnesses that complicates their disease management plan.
A collaborative approach with health care professionals such as a chronic disease nurse, social worker, pharmacist, dietitian, and physician is used to better manage these chronic diseases and their complications. The team also provides patients and their caregivers with the knowledge, skills, and confidence to more effectively self-manage their chronic illnesses with targeted and effective strategies.
The interprofessional collaborative team approach coupled with a patient-centered focus, integrates self-management goals to maximize the effectiveness of medications, diet, exercise, and other lifestyle changes.
Mental Health Program
The London Family Health Team’s social workers work provides counselling to support your mental and emotional well-being whether you have a diagnosis or just need help to learn new ways to respond to stressful events in your life. Referrals, advocacy, personal counselling, and education are all part of social work services. We work closely with your family doctor and other health professionals to support your care. Social Workers at the London Family Health Team are registered members of the Ontario College of Social Workers and Social Service, which regulates and promotes the ethical and professional practice of social work in this province.
We service rostered patients starting at 14 years of age throughout adulthood. Our services start with a RAM appointment (Rapid Assessment Model) to determine the most appropriate service plan for you. 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.
Some examples where social workers can help include:
- School stress
- Work stress
- Anxiety/ depression/ mental health disorders
- Relationship difficulties
- Life transitions
- Grief and loss
- Problem solving
- Unhealthy coping strategies
- Navigating community supports/service
- Emotionally managing chronic conditions/pain
- And much more….
The London Family Health Team dietitian provides nutrition screening and counselling to patients in need of nutrition, education, management, and support for their chronic illnesses such as kidney disease, liver disease, diabetes, hypertension, etc. The service aims to help patients achieve optimal health outcomes through reducing disease complication and empowering patients to self-manage chronic condition through lifestyle changes.
Medication Management Services
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.
Hospital Discharge Medication Reconciliation Service
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.
Lung Health Management Program
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.
Weight Management Program
Facilitated by our dietitian, chronic disease nurse, social worker and pharmacist, the London Family Health Team uses an interdisciplinary approach to weight management. Through “Healthy You!”, a seven-week group program, patients learn healthy lifestyle changes that help them understand how nutrition, physical activity, self-esteem, our behaviours, and the environment affect our body.
Self-management strategies include making better food choices, increasing physical activity, and practicing self-care. The program includes both educational sessions, and hands-on practice. Program content includes: food-drug interactions, menu-planning, label reading, how to choose healthy options when dining out, managing roadblocks, a grocery store tour, and cooking demonstration in a fun and supportive setting.
Smoking Cessation Service
The Smoking Cessation Service supports patients with counselling and medication management to meet their goal of quitting smoking.
Cancer Screening Service
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.