Services

The CLFHT will focus on the provision of chronic disease management services to patients with diabetes, cardio-vascular disease, arthritis, mental illness, strokes, asthma, chronic respiratory disease and other chronic conditions. Research of treatment protocols for patients with chronic disease indicate that the primary areas of focus should include:

  • Stop smoking
  • Improve nutrition
  • Exercise daily
  • Take medications as directed
  • Reduce stress levels.

Formal linkages will be developed with these community based primary care providers to improve access to primary care services, provide a wider range of services to residents, increase the scope and volume of current services and to develop a integrated primary care system. The CLFHT will also work closely with the CEEH hospital and Bluewater Health to ensure that there is close link between inpatient hospital care, the Emergency Department, diagnostic laboratory and radiology services, day surgery services, eye surgery services and other specialty programs currently provided at the CEEH site.

A recent health needs assessment of the primary care needs of Central Lambton and rural Lambton residents has indicated that there is a need to introduce a number of new primary care programs to improve access to primary care services in the community. Specific program needs include:

  • Expanded community based mental health and addictions programs for children, teenagers, adolescents, and the elderly.
  • Increased wound management services for patients with diabetes, post-surgical patients and others suffering from infectious wounds.
  • Improved access to diabetes education programs and services.
  • Foot care services including chiropody, podiatry and public education are required for diabetic patients.
  • Cardiac rehabilitation including physiotherapy, occupational therapy, speech therapy, etc should be provided in Central Lambton for cardiac, stroke and post-surgical patients. This will be provided in association with the Oil Heritage Community Centre who will provide physiotherapy and kinesiology staff.
  • Health promotion and illness prevention programs that focus on the needs of the frail elderly, rural residents living alone, low-income residents and single parent families.
  • Nutritional counseling, obesity management and education for teenagers and young adults as well as diabetic, cardiac and stroke patients are required.
  • Paediatric and rheumatology clinics for children and residents with arthritis.
  • A patient navigation system to assist patients in accessing primary care and chronic disease management services in the community. Elderly patients who live in rural communities have difficulty accessing services because service delivery is not integrated and coordinated.
  • Social work services for all age groups including teenagers, the elderly, confused patients, palliative care patients and patients with complex health problems.
  • Medical Day programs for patients with chronic illnesses who could benefit from therapeutic programs and professional nursing services to maintain their health.
  • Nurse practitioners clinics to serve “orphan patients” who do not have a family physician and to provide care to patients in nursing homes, seniors housing or other community settings.
  • Women’s wellness programs, including breast screening, mammography, sexual health education for teenagers and cervical cancer screening.
  • Community based palliative care services which will include public education, caregiver support, volunteer training, respite care and related services.

In the first phase of development of the Central Lambton FHT, nurse practitioners and primary care nurses from the FHT will work closely with the current family physicians in caring for patients in their offices, in the hospital, in the Emergency Department and in long term care facilities. Physicians and nurse practitioners will work closely together to develop confidence and trust in their working relationship, to ensure that common standards of practice are followed and to clearly define their roles in these various settings. Over time, the Nurse Practitioners, primary care nurses and family physicians will develop specific programs focusing on chronic disease management for patients with diabetes, wounds, arthritis, stokes, cardio-vascular disease, asthma, chronic obstructive lung disease, women’s wellness, palliative care and other programs. The FHT will draw upon the resources of other FHTs across the Province in the development of these programs and services.

 

 For more information click on the following links:

Cancer Prevention - It’s Your Body – It’s Your Choice

 Flu Season In Lambton County