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 completes applications where appropriate.
Below, you will find links to information to help you make the best decision for your patients when referring them for specialized care. You will also find links to centralized access programs such as Waterloo Wellington Diabetes and system coordinated access for orthopaedics.
When you refer a patient, a Care Coordinator:
- completes a comprehensive psycho-social, functional and health assessment
- develops, or works with you to develop, a care plan to support transitions from hospital to home and to safely remain in the community.
- links the patient 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 professional services from the following, as appropriate: nurses, occupational therapists, physiotherapists, dietitians, speech language pathologists, social workers, personal support workers.
If you have a patient with an acute or chronic care need that is not met with current treatments and supports, we can provide a variety of services to facilitate care in the home and the community.
See the Primary Care Information Sheet.pdf for details.
Request for Home and Community Care Support Services
If you have a patient with an acute or chronic care need that is not met with current treatment and supports, home and community care (formerly the LHIN) can provide a variety of home and community-based services to help. In addition, Home and Community Care Support Services assesses and determines eligibility for long-term care and completes applications where appropriate.
The form is to be completed by physicians in the community who wish to refer patients to Home and Community Care Support Services. Please ensure the form is completed as fully as possible to avoid any delays in activating the requested services.
Completed forms should be faxed to: 519 883 5550.
Medical Assistance in Dying
Home and Community Care Support Services in collaboration with our regional MAID assessment team and our Regional MAID Care Coordination Service (WWCCS) have launched 2 new forms to streamline the MAID referral process. The purpose of the Referral form (031A) is to provide clarity for Physicians/Clinicians on the nature of the support they require for patients who are requesting additional information or wish to proceed with a MAID referral. Once the referral is received the WWCCS will begin to action a request for a MAID assessment within one business day and will complete the referral within a two week time frame. The requesting clinician will be contacted within one week with a status update.
The Eligibility Assessment for Medical Assistance in Dying (MAID) Fax form, may be used by staff that receive requests from MAID Assessors for additional medical information. This fax form (068) may be faxed to the Most Responsible Physician (MRP) to notify the MRP that further medical information related to the patients diagnosis has been requested by the MAID Assessor to complete the referral.
Centralized access to community agencies and services
Grand River Hospital
MENTAL HEALTH, ADDICTIONS AND CRISIS CARE CENTRALIZED ACCESS
HEALTH CARE CONNECT
Programs and Resources to Support Referrals
Please use our dedicated Primary Care Provider phone line: 1 844 388 5541 for assistance
OHIP Billing Fee Codes
You can use the following billing codes* when working with us:
Home care application: The service rendered by the most responsible physician for completion and submission of a home care service request form to Home and Community Care Support Services on behalf of a patient for whom the physician provides on-going medical care. The amount payable for this service is as shown and is in addition to the assessment fee payable, where applicable. The amount payable for completion of the home care service request form if completed in whole or in part by a person other than the physician or the physician’s employee is nil.
|K070||31.75||Completing a Home and Community Care Support Services Referral (SOB Pg. 148)|
|148||||Long-term Care Application (SOB Pg. 148)|
Home care supervision: The service rendered by the most responsible physician for personally providing medical advice, direction or information to health care staff of Home and Community Care Support Services or contractor on behalf of a patient for whom the physician provides on-going medical care. The date, question, response and identity of the health care staff must be recorded in the patient’s medical record. The amount payable for home care supervision without the required record of service in the patient’s medical record is nil. The amount payable for home care supervision rendered on the same day as a consultation or visit by the same physician with the same patient is nil.
Acute Home Care Supervision (SOB Pg. 148)
(Maximum 1 every week for the first 8 weeks following admission to home care program)
Chronic Home Care Supervision (SOB Pg. 148)
(Maximum 2 per month commencing in the 9th week following admission to the home care program)
|K121||||Hospital In-patient Case Conference (SOB Pg. 131)|
Long-term Care/ LHIN Case Conference Regarding a Home and Community Care Support Services patient (SOB pg. 134-135)
Note: case conference regarding a Home and Community Care Support Services 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 physician’s regulated social workers, employees of a Home and Community Care Support Services and/or regulated health professionals
|K700 / K704 / K702 / K703 / K704 / K707||||Outpatient Case Conferences (SOB Pg. 131)|
|K705||||Long-term Care - High risk patient case conference (SOB Pg. 135)|
Home care visits:
|B960||Travel - Special visits to patients homes (other than long-term institutions)|
|B966||Travel - Special visits premium - Palliative Home Care Visit|
|B986||Travel - Special visits premium - Geriatric Home Visits|
|B988||Visit - Special visits premium - Geriatric Home Visits unlimited travel and visits|
|B990||Visit - Special visits to patients homes (other than long-term institutions)|
|B998||Visit - Palliative Home Care Unlimited travel and visits|
*Schedule of Benefits for Physician Services under the Health Insurance Act
Hospice Palliative Care
For referral information and forms for the Hospice Palliative Care Team visit their page.