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Chronic disease management clinic

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 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. 

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 

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.

The Aline-Chrétien Health Hub is integrated with the Ocean eReferral Network portal. Click the link to access the request.

The Ocean eReferral platform allows you to create and submit requests directly from most electronic medical record systems for physicians in the community.

Therefore, we encourage you to take advantage of this free platform that greatly simplifies and streamlines the process of managing test requests.

Requests received via Ocean will always be clearer and more complete, and allow for more effective and efficient communication with providers and patients.

For more information or assistance with the Ocean integration process, email or visit their website by clicking here.

Medical referral form

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