Model of Care
The Central East CCDC was established to assess and support clients with diabetes who have complex needs, such as co-morbid health conditions that require intensive case management. The CCDC offers a single point of access to a specialized inter-professional team. It is a care delivery model for people with diabetes who need more contact, more resources and more follow-up across health care and social services systems. Care is provided over a shorter term, patient-centred, goal specific and allows for frequent follow-up.
In the Central East region, the Home and Community Care Support Services Central East completes the referral and assessment of clients for the CCDC and there are three care delivery sites located at Peterborough Regional Health Centre, Lakeridge Health Whitby, and The Scarborough Hospital – General Campus.
Who is Appropriate for the CCDC?
To be referred, the client must be 18 years of age or older, with Type 1 or Type 2 diabetes and have one or more of the following:
- Multiple episodes of inadequate glycemic control and/or significant co-morbidities impacting glycemic control;
- Serious mental health issues, barriers in accessing health care, frail elderly, mobility issues, and other determinants of health;
Recurrent emergency department visits or hospitalizations;
- Would benefit from an inter-professional team who coordinates the care the client is receiving from multiple health care providers.
- To enhance access for clients to the CCDC across the Central East region, innovative health care delivery systems such as Ontario Telehealth Network (OTN) will be used.
The team consists of the following experienced registered professionals:
- Nurse Practitioners
- Registered Nurses
- Registered Dietitians
- Social Workers
As clients meet their goals and their self-management goals and their condition stabilizes, they are transitioned to a Diabetes Education Program or a primary care provider. The Central East CCDC team works directly with an individual’s primary care provider to ensure continuity of care and a coordinated approach to diabetes management and treatment.
How to Refer
Admission to the Central East CCDC is completed through Home and Community Care Support Services Central East. Please complete the Central East Centralized Diabetes Intake Referral Form and fax it to 905-444-2544.
Call the Centralized Diabetes Intake service at 1-888-997-9996 and you will be connected with a care coordinator who will facilitate the referral.
See Our Centre for Complex Diabetes Care Fact Sheet »
Building Healthier Communities with our Diabetes Patients and Partners »
New video highlights improved access to diabetes services across Central East region »
Hi, I'm Mari, and this is my patient experience.