Overview
Chronic illness needs rhythm: scheduled labs, home monitoring, medication adjustments, and early recognition of complications. We align discussions with Canadian references—examples include Diabetes Canada for glycemic targets and Hypertension Canada for blood pressure—and coordinate with pharmacy, dietitians, respirology, cardiology, and nephrology as needed.
Your care plan states targets (e.g., BP, A1c, inhaler technique), who adjusts what, and when to seek urgent care.
What’s included
- Scheduled labs and vitals; diabetes home glucose or CGM review when indicated
- Medication optimization, deprescribing, and interaction checks
- Education on self-monitoring (BP, peak flow, glucose)
- Specialist co-management with clear communication
- Action plans for acute exacerbations (asthma/COPD)
- Foot and eye screening for diabetes; kidney protection strategies
Who it’s for
Patients with one or more chronic diagnoses needing proactive follow-up, medication titration, or help navigating multiple specialists.