For HNHB Hospital and Primary Care Partners

Referring to us is simple.

You can do this one of two ways:

  1. Complete the Request for Home and Community Care Support Services HNHB form and fax it to the appropriate location.  Refer to page 2 of the form for fax numbers.
  2. Primary Care Partners: in addition to using the form above, you may also connect directly with the Care Coordinator aligned with your office/practice.

Long-Term Care Placement – For patients waiting in hospital or in the community, we also assess and determine eligibility for long-term care and respite care.   If your patient is interested in long-term care placement and has functional needs or cognitive deficit(s), please complete the Request for Home and Community Care Support Services HNHB form and indicate this in the “medical order” section on page 1.  Fax the completed form to the appropriate location.  Refer to page 2 of the form for fax numbers.

Health Assessment Form is requested when the assessing Care Coordinator has determined that the patient is eligible for long-term care placement, and must be completed and signed by a physician or nurse practitioner. Access common OHIP Billing Codes on our Partners page here.

For assistance with making a referral, contact our Information and Referral Team at  access@hccontario.ca or 1-800-810-0000.

Forms

MEDICAL ORDER AND PRESCRIPTION FORMS  

FormUsage
Medical Order Form - GeneralTo order general medications, including wound care and maintenance for urinary catheters
Medical Order Form: Protocol for Vascular Access Devices (VAD)To order care relating to vascular access devices in adults (in accordance with the Vascular Access Maintenance Protocol)
Medical Order Form: Protocol for Central Vascular Access Devices (CVAD) for Pediatric Patients (McMaster Hospital)To order care relating to vascular access devices in children
Medical Order Form: Care and Maintenance of Midline CatheterTo order midline catheter maintenance
Medical Order Form: Administration of Influenza Vaccine FormTo order administration of influenza vaccine
Medical Order Form: Medical Assistance in Dying (MAiD)To order nursing and IV starts for MAiD
Medical Order Form: Protocol for Home Parenteral Nutrition (PPN or TPN) for the Adult PopulationTo order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for adult patients
Medical Order Form: Protocol for Pediatric Home Parenteral Nutrition (PPN or TPN) at McMaster Children's Hospital (MCH) HamiltonTo order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital
Medical Supplies CatalogueTo order from HNHB’s medical supplies catalogue
First Dose – IV Medications FormTo order first dose IV medications to be administered to patients in the community
Iron Infusion FormTo order intravenous iron replacement
Vancomycin & Aminoglycoside (Gentamicin, Tobramycin) Prescription FormTo order IV vancomycin and/or aminoglycosides for patients in the community

NEGATIVE PRESSURE WOUND THERAPY (NPWT) SERVICES ​

Negative Pressure Wound Therapy (NPWT) Referral FormTo request negative pressure wound therapy for pressure ulcers, diabetic foot ulcers, arterial ulcers, venous ulcers and surgical wounds
Negative Pressure Wound Therapy (NPWT) Special Circumstances Referral FormTo request negative pressure wound therapy for patients with special circumstances, e.g. patient has had a wide excision with skin graft or an STSG greater than 2 cm squared

PALLIATIVE APPROACH TO CARE FORMS AND MEDICAL ORDERS 

Hospice Referral FormTo refer a patient to (apply for) hospice and hospice-type services
Letter of Understanding for the Pronouncement and Certification of DeathTo identify who will complete pronouncement and certification of death for an expected death at home
Plan of Treatment Regarding Cardiopulmonary Resuscitation (CPR) FormTo clearly communicate a patient's plan of care relating to the provision of CPR.
Palliative Symptom Response Order FormFor the management of rapid-onset, unanticipated symptoms for patients nearing end–of-life and no longer able to swallow oral medications. The medication on this order form is limited to support short duration of symptom management (48 hours) until further medications are ordered.
Palliative Symptom Response Guidelines
Patient and Family Information about Palliative Symptom Response Medication
Palliative Care Outreach Team (PCOT) Referral Forms by sub-region:To request the services of the Palliative Care Outreach Teams.

The Palliative Care Outreach Team (PCOT) is a group of specialist providers who practice as an inter-professional team. The PCOT specialist may include Palliative Care Physicians, Nurse Practitioners, Clinical Nurse Specialists, Nurse Clinicians, Psychosocial Spiritual and Bereavement Clinicians, and Clinical Navigators.

PCOT members have a shared accountability with primary care providers, for patients who require a palliative approach to care.

The team is also a source of expert advice and consultation; and provides specialist palliative care and services for patients with complex needs, mainly in their homes and residences.
Hamilton
Niagara PCOT
Haldimand Norfolk PCOT
Burlington PCOT
Brant (please use the Hospice Referral Form and order Outreach Services)

OTHER FORMS

Ceftriaxone Protocol Medical Referral FormTo order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS)
Complex Care and Rehabilitation Application FormCompleted with the patient as an application to one of the complex care streams: short-term or long-term medically complex, activation and restoration, end of life or behavioural; low intensity rehab or high intensity rehab
Complex Care Expedited Admission FormTo notify us of a patient’s admission to a complex care bed before an application could be completed
HPG User Access Authorization FormFor hospital partners who use Health Partner Gateway to receive patient referrals.
Mental Health & Addictions Nurse Referral FormTo request the services of the Mental Health & Additions Nurse, the patient must be:
A student registered in school and who is no older than 21 years of age (may include home instruction)
In need of services or related treatment to an identified and/or suspected mental health and/or addictions issue
Aware of and consenting to the referral
Additionally, there must be a clearly defined role for the Mental Health & Addictions Nurse
Respiratory Therapy Referral FormFor patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital
Community Paramedicine High Intensity LTC Communication FormFor Community Paramedicine Program