What can we offer your patients?
If you have a patient with an acute or chronic care need that is not met with current treatment and supports, we can provide a variety of home and community-based services to help. In addition, we assess and determine eligibility for long-term care and complete applications where appropriate.
When you refer a patient to us, a Care Coordinator;
- Completes a comprehensive psycho-social, functional health assessment
- Connects patients with the care they need by developing service plans to support patients in transitions from hospital to home and to safely remain in the community.
- Links patients to the appropriate health system and community resources (e.g.: Meals on Wheels, transportation, day programs, etc.).
Your patient will also be assessed for in-home or in-community (clinic) professional services from the following, as appropriate:
Nurses: wound care, IV and inject-able medication administration, chronic disease management and teaching, for example, COPD, CHF, Diabetes, peritoneal dialysis, palliative care, mental health and pediatric care.
Occupational Therapists: physical environment and cognitive assessments, assistive devices and home safety, mental health, energy conservation strategies.
Physiotherapists: balance and strength training, exercise regimen.
Dieticians: for nutritional counseling.
Speech Language Pathologists: swallowing and speech assessments and therapies.
Social Workers: issues related to housing, finances, neglect or suspected abuse.
Personal Support Workers: personal care assistance, nutritional support, medication reminders, caregiver relief, activation.
How to make a referral to us:
The Medical Referral form(s) below is to be completed by physicians/nurses in the community who wish to refer patients to us. Please ensure the form is as fully completed as possible to prevent delays. Completed forms should be faxed to the following numbers:
Referral and Treatment Form
Referral and Treatment Form - Pain Medication
Medical Update Request Form
Medical Update Request Form - Wound
Diabetes Education Referral Form
Mental Health and Addictions Nurses for Youth Form (English)
Mental Health and Addictions Nurses for Youth Form (Français)
Telehomecare Referral Form
Keep in mind the following OHIP Billing Codes when working with us:
- K070 for completing a home and community care 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 a home and community care patient. Note the K124 requires participation by the physician most responsible for the care of the patient and at least two other participants that include physicians, regulated social workers, our employees and/or other regulated health professionals.
Navigating our Website
We have designed our website to be as engaging and user-friendly as possible. To help in navigating the site, we have developed a Website Resource Document for your reference.