Downtown & Point Douglas

Service Overview

Chronic Disease Management Clinician: The Chronic Disease Management Clinician is responsible for developing and delivering chronic disease management, prevention, and self-management programs for patients within the My Health Team network. This role involves conducting comprehensive health assessments, identifying and addressing health issues, and collaborating with patients to implement evidence-based interventions. The Clinician works closely with MyHT fee-for-service physicians, healthcare professionals, and community organizations to optimize care, focusing on health promotion and chronic disease prevention. Responsibilities include monitoring patient outcomes, providing specialized care for diabetes self-management, smoking cessation and supporting at-risk populations through outreach, education and coordination of care.

Occupational Therapist: The Occupational Therapist will contribute to client care in collaboration with MyHT fee-for-service and community health agency physicians. The Occupational Therapist will work to their full scope, providing assessments, interventions, and education to improve the well-being of patients dealing with injuries, chronic diseases, mental health challenges, and more. This role focuses on community-based care through home visits, with a focus on helping clients achieve independence and safety. The Occupational Therapist will collaborate closely with physicians and other healthcare partners, playing a key role in client-centered care, service evaluation, and ongoing development of the role.

Income Security Health Promoter: The Income Security Health Promoter plays a key role in supporting patients by connecting them to relevant financial services and resources within the Downtown/Point Douglas community. The role involves conducting outreach, identifying patients at risk for income vulnerability, and facilitating access to income security-focused interventions. In collaboration with MyHT providers, the Income Security Health Promoter develops tools and strategies to address income insecurity as a health risk, trains and mentors peer supporters, and provides education on financial literacy. The position also strengthens partnerships with community programs to enhance service delivery, ensuring comprehensive support for patients navigating financial and healthcare systems.

Housing Coordinator: The Housing Coordinator supports individuals experiencing housing insecurity through a harm reduction approach. This role involves conducting housing needs assessments, assisting clients in securing affordable and accessible housing, and providing brief support for housing stability and eviction prevention. The Housing Coordinator collaborates with MyHT providers, service providers and case managers to address individual needs related to housing, employment, education, and daily living activities. They also provide education on tenant and landlord rights, conduct on-site and home visits for system navigation and advocacy, and proactively connect clients to emergency shelters and community resources. In urgent situations where no other resources are available, the Housing Coordinator liaises with housing services to support advocacy efforts.

Community Pharmacist: For physicians, this pharmacist provides valuable support through detailed medication reviews, identifying potential drug interactions, optimizing treatment plans, and ensuring evidence-based prescribing practices. Their expertise helps streamline care for complex patients, particularly those managing multiple chronic conditions or polypharmacy. By reducing the risks of medication-related issues, they enhance patient safety and improve outcomes. This collaborative approach strengthens the provider-patient relationship, ensuring that care remains tailored to individual needs while promoting overall wellbeing and better health management.

Primary Care Wellness Integrator: The Primary Care Wellness Integrator is responsible for assessing client needs and connecting them to relevant community resources, with a focus on mental wellness and recovery. This includes maintaining an up-to-date knowledge of community-based mental health and addiction services within the Downtown/Point Douglas area and fostering partnerships with local agencies. The role involves working collaboratively with MyHT providers, community facilitators, and peer supporters to strengthen networks, identify at-risk individuals, and provide supportive case management and wellness interventions. The Wellness Integrator also trains and mentors peer supporters, participates in interagency planning, and assists patients in navigating healthcare and social support systems, ensuring a comprehensive approach to chronic disease prevention, risk management, and recovery.

Mental Health Support Worker: The Mental Health Support Worker assists in implementing individual service plans under the direction of the clinical team. This role involves providing rehabilitative and supportive services, including skill-building, linking individuals to formal and informal support networks. The Support Worker also connects clients to community resources, promotes social integration, and advocates for access to services like housing, income security, mental health, addictions, legal aid, and healthcare & social services. Overall focus on fostering personal growth, and enhancing recovery through direct, community-based services.