The Windsor Team Care Centre is an interdisciplinary team of health care professionals that provide comprehensive healthcare support to patients of “Solo Practitioners” (i.e. Practitioners who practice within a Family Health Organization, Family Health Group, or Private Practice model of care) within Windsor.
Our goal is to work in partnership with Windsor’s Solo Practitioners to provide holistic care for patients age 16 and up and across a variety of health care needs, with a major focus on mild to moderate mental health and complex care needs.
The Windsor Team Care Centre is funded under the Ministry of Health and Long-Term Care through the Windsor Family Health Team and in partnership with the Canadian Mental Health Association. This allows our program the unique ability to provide clients with team-based care services at no cost to the client.
Clients referred to the Team Care Centre must:.
- Be 16 years old or older
- NOT be currently involved in any psychotherapy/social work services (i.e. is not currently receiving services from a psychologist and/or social worker).
- HAVE exhausted all EAP/Benefit services.
- NOT be seeking services focussed on concerns related to schizophrenia/psychotic disorders.
- NOT require specialized based services, which can be accessed in the community (i.e.: Treatment focussed on Sexual Assaults, Eating Disorders, Dementias)
The Team Care Centre’s interdisciplinary team includes a Psychiatrist, a Nurse Practitioner, Social Workers, Addiction Counselors, a Respiratory Therapist, a Registered Dietitian, an Intensive Care Coordinator, a Footcare Nurse, a Pharmacist, and a Physiotherapist. To learn more about what each member of our team does click on the tabs below!
- Diabetes (blood sugar control)
- Hyperlipidemia – elevated LDL/TG, low HDL
- Non-alcoholic fatty liver disease
- Weight management (loss/gain)
- GI disorders (diarrhea, constipation, GERD, Crohn’s, colitis, IBS, hiatal hernia)
- Nutrient deficiencies (low iron, B12)
- Vegetarian/vegan nutrition advice
- Cholecystectomy (gallbladder removal)
- Plus any other diet-related concerns people may have.
- Reducing pill burden (deprescribing)
- Substance use and potential interactions (including smoking, caffeine, herbals)
- Health and medication education
- Patient advocacy – communicating with their pharmacy
- Medication reconciliation
- Polypharmacy or polydoctoring
- Pregnancy and lactation
- Emotional support (ie. vulnerable client who requires support between other appointments)
- Completion of Coordinated Care Plans & home visits for Complex clients
- 4 or more complex/chronic conditions with targeting sub-groups -frail people, mental health and addictions, palliative population.
- High users of hospital-based services or primary care visits.
- Other considerations- economical characteristics (eg- low income, unemployed), Social determinants (housing challenges, social isolation, language).
- Collaboration with Team Care Centre NP and community agencies based on client needs
- Medical Director for services provided at the Team Care Centre
- Consultant for Clinical Care Coordinator and Mental Health Team
- Provides therapeutic management of individual client needs and needs of Mental Health Team clients.
- Female Nurse Practitioner, able to provide female based services ie: PAP, breast exam, physicals
- Counselling services to manage chronic mild to moderate mental health issues, physical health issues and manage emotions
- Cognitive Behavioural Therapy
- Narrative Therapy
- Stress Reduction
- Mindfulness etc.
- LGBTQ2+ specialized counselling services
- A psychosocial assessment will be completed with each individual during their initial session with assigned TCC social worker. A treatment plan will then be collaboratively devised.
- Services will be provided on a SHORT TERM basis (up to 10 sessions). Treatment length will be determined at the time of social work initial assessment
- Private confidential addiction counselling to those suffering the effects of illicit/licit substance use and/or gambling misuse and harmful behaviors.
- Embraces harm reduction or cessation in substance use
- Biopsychosocial approach identifying psychological, social and physiological signs and symptoms of alcohol and other substance use.
- Identify coexisting conditions (medical psychiatric, physical) that indicate the need for additional professional assessment and/or services.
- Assess and identify client’s needs and develop comprehensive individualized client centered treatment plans and identify resources and service requirements.
- Provide treatment and education on substance recovery, maintenance, relapse prevention, harm reduction and life skills.
- Advocate and Assist clients with discharge planning and accessing other community support systems and resources ie: Withdrawal Management Services(detox), CMHA, Mental Health Connections, Assessment and Referral, In-patient/Out-patient addiction treatment facilities, housing, Legal Aid, OW and ODSP.
- Support Harm reduction and medication-assisted treatment (methadone, buprenorphine or suboxone, naltrexone and Antabuse) provide referrals for Opioid Replacement therapy.
- Support healthy lifestyle changes
- Therapeutic management of clients with mild to moderate mental healthcare needs
- Clients are seen until therapeutic, or until a therapeutic goal is met
- May include support from Nurse Practitioner, Psychiatrist, Social Work, Addictions Counsellor and/or Pharmacist (determined by the Team Care Centre, based on client’s needs)
- Please note: Referrals to psychiatry are directed within the Team Care Centre, no direct referrals to psychiatry will be accepted.
- Respiratory assessments and spirometry testing (pre/post)
- COPD and Asthma education
- Smoking cessation support (Through the STOP program- which qualifies clients for 26 weeks of smoking cessation counselling & 26 weeks of FREE Nicotine Replacement Therapy)
- Diabetic Foot Assessments
- Treatment of current problems and prevention of future foot health issues
- Health education on how to properly care for feet, in hopes of preventing more serious issues in the future
- Functional activity and tolerance testing
- Personalized therapeutic exercise plans
- Chronic pain, work and occupations re-training
- Completes intake assessments
- Health Education
- Generates referrals to other Team Care Centre ancillary services as client needs are identified.
Q & A:
Q: Why only Windsor Docs?
A: Currently our scope is Windsor but as we show the value of our program we hope to expand services across the Windsor/Essex Region
Q: Can the client live outside of Windsor?
A: If the doctor currently has a practice in Windsor we will service the client regardless of their home address.
Q: Can we as a community agency refer into TCC?
A: You can help facilitate the referral through the solo family doctor by providing the physician’s contact to our team
Q: Is this pilot?
A: No, this is dollars that was added to base funding for the family health team to expand services to solo practitioners to provide them the same supports that a FHT has
Q: Are there any fees associated with your services?
Q: Hours of Operation
Mondays: 8:30 – 6PM
Tuesday, Thursday & Friday: 8:30 – 4:30PM
Wednesday: 8:30 – 8PM
For more information or to receive referral forms contact 519-250-5524 or firstname.lastname@example.org