Centre de santé et de services sociaux de Témiscaming-et-de-Kipawa

Services for Individuals Afflicted with Chronic Diseases

Team Dedicated to Monitoring Chronic Diseases

• A team of nurses, nutritionists, social workers, and doctors ensure that individuals afflicted with chronic diseases receive services that are especially designed for their condition so as to improve their quality of life. Follow-ups are tailored to the individual's needs.
  

Integrated Monitoring Clinic for Diabetics

This program provides integrated educational and monitoring services to diabetics. Through regular and continuous monitoring, the team is able to provide the patient with the support required for effective management of the disease.

The types of services offered include:

• Individualized Basic Education
  Provided by a nurse and a nutritionist, the number of meetings varies according to the needs of each individual. Basic information promoting
  self-care is provided to new diabetics prior to integrating them in group monitoring. More intensive individual monitoring is also provided to individuals with specific problems.
• Regular and Continuous Monitoring:
  • Group Meetings (3 times a year)
    During such meetings, individuals receive follow-ups on several diagnostic tests related to their diabetes. They also attend a preventive information briefing given by a nurse or nutritionist, followed by an individual meeting with a nurse, doctor, or nutritionist.
  • Remote Monitoring
    This involves telephone monitoring set up to meet the needs of individuals who prefer not to participate in group meetings or who are not able to attend.
    
    The same laboratory tests will be carried out, regardless of the type of monitoring chosen. Patients can also set up personal meetings with a doctor, depending on availability.
    
    Patients are routinely monitored in a manner which best suits them, either remotely or in groups.
    

The clinic's annual reports show compelling results:
- improved glycemic control
- better management of the disease
- reduction in related complications
- low rate of emergency consultations and less hospitalization

Monitoring Clinic for Patients Suffering from CVD

• This is a two-part program:
  1. Education on life changes after a heart attack or stroke
     
     A nurse, in collaboration with a nutritionist, offers individual meetings covering various aspects on the management of heart disease.
     
  2. Group information meetings on CVDs
     
     Group activities are provided to the general public and cover CVD awareness and reduction of risk factors.
     

Anticoagulation Monitoring Clinic

• This program is offered to patients who need to take blood thinners for several weeks or for an extended period of time. A nurse provides personalized monitoring consisting of education on the implications of anticoagulant therapy and regular monitoring of diagnostic test results.
  

Self-Care Program

• This new program, designed for individuals living with chronic diseases, as well as for their loved ones, was introduced in the fall of 2010.
  
  Please view our PDF flyer for more information This document is only available in French