Complex Chronic Disease Management Clinic

The purpose of the Complex Chronic Disease Management Clinic (CCDMC)is to provide intensive management of complex medical patients to effectively decrease exacerbations and hospital presentations.

Services provided may include:

• provide family physicians and specialists with patient's plan of care within 2-3 business days of the patient's visit
• serve as a single point of contact for both patients and family physicians to assist in navigating the health care system
• facilitate communication between all care providers
• the clinic aims to minimize poly-pharmacy and invasive investigation/intervention, while at the same time maximize care coordination and patient self-management
• CCDMC does not replace the care of a family physician. The clinic will adjust medications and assist in the management of the patient's medical issues unless specifically requested not to by the family doctor or a specialist
• patients will be discharged from the CCDMC when they are comfortable going 3 months without a clinic visit