For HNHB Hospital and Primary Care Partners
Referring to us is simple.
You can do this one of two ways:
- 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.
- 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.
A Health Assessment Form (opens in a new tab) 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.
For assistance with making a referral, contact our Information and Referral Team at access@hccontario.ca or 1-800-810-0000.
For Long-Term Care Partners
Please complete and fax the Long-Term Care Home Referral for Service form to request one or more of the following services for residents:
- Nursing
- Wound Care
- Speech Language Pathology for Swallowing Assessment
Forms
MEDICAL ORDER AND PRESCRIPTION FORMS
| Form | Usage |
| Medical Order Form - General | To 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 Catheter | To order midline catheter maintenance |
| Medical Order Form: Administration of Influenza Vaccine Form | To 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 Population | To 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) Hamilton | To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital |
| Medical Supplies Catalogue | To order from HNHB’s medical supplies catalogue |
| First Dose – IV Medications Form | To order first dose IV medications to be administered to patients in the community |
| Iron Infusion Order Form | To order intravenous iron replacement |
| Vancomycin & Aminoglycoside (Gentamicin, Tobramycin) Prescription Form | To order IV vancomycin and/or aminoglycosides for patients in the community |
| Pediatric Milrinone Infusion Therapy | To order Milrinone Infusion Therapy for pediatrics patients |
| Milrinone Home Infusion Order Form for Adult Patients | To order Milrinone Infusion Therapy for adult patients. |
NEGATIVE PRESSURE WOUND THERAPY (NPWT) SERVICES
| Negative Pressure Wound Therapy (NPWT) Referral Form | To 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 Form | To 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 Form | To refer a patient to (apply for) hospice and hospice-type services |
| Letter of Understanding for the Pronouncement and Certification of Death | To identify who will complete pronouncement and certification of death for an expected death at home |
| Plan of Treatment Regarding Cardiopulmonary Resuscitation (CPR) Form | To clearly communicate a patient's plan of care relating to the provision of CPR. |
| Palliative Symptom Response Order Form | For 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 | Guidelines how to use the Palliative Symptom Response Order Form. |
| Patient and Family Information about Palliative Symptom Response Medication | Information sheet for patients and families. |
| 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 - PCOT Referral Form | |
| Niagara PCOT Referral Form | |
| Haldimand Norfolk PCOT Referral Form | |
| Burlington PCOT Referral Form | |
| Brant (please use the Hospice Referral Form and order Outreach Services) | |
| Margaret’s Place Palliative Overnight Respite ReferralForm | To be completed and signed by an HCCSS Care Coordinator to refer a patient to Margaret’s Place for Palliative Overnight Respite care |
OTHER FORMS
| Ceftriaxone Protocol Medical Referral Form | To order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS) |
| HPG User Access Authorization Form | For hospital partners who use Health Partner Gateway to receive patient referrals. |
| Mental Health & Addictions Nurse Referral Form | To 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 Form | For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital |
| Community Paramedicine Communication Form | Paramedic Services will communicate back to Home and Community Care Support Services using the HNHB Community Paramedicine Communication Form |