Community Care Team (CCT)

The Community Care Team at Health for All Family Health Team is an interprofessional primary care team supporting Eastern York Region health providers, community organizations, and residents.

To be eligible for our services, patients must either:

a) live in Eastern York Region, our “catchment area”

– *OR* –

b) be referred by a provider/organization operating in
Eastern York Region

The borders of our catchment area are:

North Border: Davis Dr.
South Border: Steeles Ave.
West Border: Highway 404/Langstaff/Yonge St.
East Border: York-Durham Townline

Catchment area

To connect with the Community Care Team and find out how we can work together, please call 905-472-2200 ext. 290.

Residents: Call us to self-refer.
Providers or organizations: Referrals to our services can be submitted via fax or via Ocean (e-referrals). Please click the button below to download a patient referral form.

Referral Form

Please note: CCT services can be provided either in-person and virtually.

Case Manager

Our Case Manager, Kathleen, can help guide patients through the health care system to ensure they receive quality care and continuity of services. Case manager services include:

· Guidance on health system navigation

· Assistance with applications for services (OHIP, ODSP, EI)

· Coordination of patient health care programs for continuity of care

· Advocacy for services and supports

· Connecting to community and government services (employment, housing, funding)

Nurse Practitioner

Nurse Practitioners (NPs) are healthcare professionals with advanced education and training in diagnosing and managing acute and chronic medical conditions. They work independently and collaboratively with other healthcare professionals to provide comprehensive care to patients of all ages.

NPs have the authority to perform many of the same medical functions as Family Doctors, including diagnosing and treating illnesses, ordering and interpreting diagnostic tests, prescribing medications (including controlled substances), admitting, treating and discharging patients from hospital, performing medical procedures, and making referrals to specialists.

In addition, NPs are also trained to provide health promotion and disease prevention services, such as counseling patients on lifestyle modifications, and educating patients and their families on managing their health conditions. NPs are an important part of the healthcare team, providing high-quality, accessible, and patient-centered care to help improve the health outcomes of their patients.

Our Nurse Practitioner, Stephanie, can provide accessible primary care to individuals and support to physicians within the community. Some of these services include:

Primary Care Services:

· Cancer screening

· Specialist referrals

· Prenatal care, well baby visits and vaccinations

· Chronic disease management

· Mental health support

· Family planning

Pharmacist

Our Pharmacist, Margaret, can provide education on safe and effective use of medications. Our pharmacy services include:

· Smoking cessation: In partnership with the STOP with FHT program, our pharmacist can provide free Nicotine Replacement Therapy (NRTs) to patients in the area http://smokingcessation.camh.ca/

· Consultation on medication for effectiveness, safety (children, pregnancy and seniors), interactions and accessibility

· CBT-Insomnia coaching

· Deprescribing (e.g. benzodiazepines, opioids, proton pump inhibitors)

· Chronic disease management (e.g. hypertension, cholesterol, mental health, diabetes, asthma, osteoporosis, insomnia, etc.)

Dietitian

Our Registered Dietitian, Gigi, can provide guidance and counselling (individual and group) regarding a range of diet and nutrition topics including:

· General Healthy Eating

· Chronic Disease Management (eg. Hypertension, prediabetes, Type 2 Diabetes, Dyslipidemia, Osteoporosis, etc.)

· Irritable Bowel Syndrome, HeartBurn, GERD, Fatty Liver, Bowel Concerns (constipation, diarrhea)

· Managing weight concerns using a Health at Every Size (HAES) approach and weight inclusive practice

 ·Disordered eating patterns and healing relationship with food

· Nutrition throughout the lifecycle (infants, child/adolescent, adulthood, elderly nutrition)

· Vegetarian or vegan diets

Social Worker

Our Social Worker, Phong, can provide individual, family and group counselling to support individuals with their mental health. Her services cover:

· Stress, separation, adjustment, grief counselling

· Mental health support

· Addiction and substance abuse

· LGBTQ2S+

Health Promoter

Our Health Promoter advocates for health services through an equity lens. With the exception of group presentations, our health promoter does not provide frontline services but instead helps promote systems and supports to ensure health for all. This role includes:

· Advocacy and enablement of conditions to help people to achieve their full health potential

· Building and fostering community and government partnerships

· Consideration of the Social Determinants of Health and their impact on access to health and health services

· Implementation of evaluation and monitoring strategies to ensure services are meeting the needs of patients

· Group presentations and education regarding a variety of health topics