Centre of clinical excellence in chronic disease management

The Chronic Disease Management Clinic is offered by a team of different health professionals, including:

  • a physician 
  • a nurse 
  • a care coordinator 
  • a dietitian
  • a physiotherapist 
  • a social worker 
  • an occupational therapist 
  • a psychologist 
  • a pharmacist 
  • family physician or nurse practitioner in the community

All of these health care professionals work together with the client and their loved ones to provide comprehensive health care while taking into account the client's overall situation. 

This program is designed to support the client, their family members and the family physician in the management of chronic diseases. 

Client Participation

This program requires the active participation of clients in the development of the care plan.

This includes:

  • identifying care goals
  • selecting activities that will help achieve these goals
  • making decisions about care tailored to the goals 

After the first appointment 

Depending on health needs and preferences, the team will support the patient and offer regular follow-ups after the first appointment. 

These follow-ups can be done:

  • by phone 
  • by telehealth (video conference) 
  • in person at the clinic

The family physician will remain the first point of contact in the community and will guide the patient in implementing the care plan made with the patient and the team.


Hôpital Montfort

This service at the Aline-Chrétien Health Hub is offered by Hôpital Montfort.

This service is also available by videoconference or telephone.

This service requires a referral from a healthcare professional.

Clients who have an appointment will receive an automated reminder by phone and/or email up to 5 days prior to their appointment.


Icône carrefour vert

Wing G, Local 1G300B

Phone: 613-288-5344, ext. 3046
Fax: 613-688-1086