Home and Community Care Support Services North West is 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.
If you have a patient who is requesting more information on Medical Assistance in Dying (MAiD), or you would like more information, please contact our Regional MAiD Coordinator at 1-800-626-5406 or visit our website.
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.)
Common OHIP Billing Codes
Advice and services are covered by OHIP. Below, please find the common billing codes to be used when working with the Home and Community Care Support Services North West.
- KO70 for completing a referral
- K071 and K072 for acute and chronic home care supervision (for personally providing medical advice, direction or information to Home and Community Care Support Services North West or delegated health-care staff)
- K124 for a case conference regarding a 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 of Home and Community Care Support Services North West and/or regulated health professionals.
community health portal
Communication among health-care providers is key to improving people's care experience, and smoothing transitions between care settings, for example from hospital to home. The Community Health Portal provides hospitals, primary care and other care partners with
real-time health information about Home and Community Care Support Services North West patients. Service providers, physicians and hospital staff can look up patients and see a summary of their Home and Community Care services and access their patient assessment(s) and other patient status documentation shared by the Care Coordinator. Patient information can be accessed as long as the patient is actively receiving Home and Community Care services, and has given consent for their information to be shared.
New patient assessments or re-assessments are shared automatically when completed by the Care Coordinator, so physicians and care providers viewing the patient record always see the most recent assessment.
In addition to assessments and other formal documents, as a patient's condition, or care needs change, the Care Coordinator can share the details of those changes as documented in Client Health and Related Information System (CHRIS) notes.