We are committed to working together with partners across the health-care system – physicians, specialists, nurse practitioners, contracted service providers as well as community support services agencies and others – to deliver high quality care for people in communities across Ontario.
If you have a patient with an acute or chronic condition whose needs are not able to be met through current treatment and supports, we can provide a variety of home and community-based services to help.
Our team of professionals includes Nurses, Occupational Therapists, Physiotherapists, Dietitians, Speech Language Pathologists, Social Workers and Personal Support Workers. We can also arrange a more supportive living environment, either at home or in the community, for patients with health-care needs that cannot continue to be met in their current situation.
A team approach
When you refer a patient to our services, a Care Coordinator will work with you and your patient to ensure continuation of the best possible care. The Care Coordinator will:
- complete a comprehensive psycho-social, functional and health assessment
- develop, or work with you to develop, a care plan to support transitions from hospital to home and to safely remain in the community
- link the patient to appropriate health system and community resources (e.g. Meals on Wheels, transportation, day programs, etc.)
Working Better Together—Achieving Coordinated Care.
Patients, caregivers, health care providers,
and community support agencies working to improve a patient’s journey through the health care system.
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Common OHIP Billing Codes
Our advice and services are covered by OHIP. Below, please find the common billing codes to be used when working with us.
- KO70 for completing a referral
- K071 and K072 for acute and chronic home care supervision (for personally providing medical advice, direction or information to us or delegated health-care staff)
- K124 for a case conference regarding patient. Note the K124 requires participation by the physician most responsible for the care of the patient and at least 2 other participants that include physicians, regulated social workers, employees and/or regulated health professionals.