Région de Champlain

Application for Determination of Eligibility for Long-Term Care – English

Authorization for Release of Personal Health Information Form

What is the Caregiver Distress Respite Program?
Your Care Coordinator has determined that you are eligible for this program that offers support to caregivers. To give caregivers temporary respite, the program provides the patient with additional support from personal support workers (PSWs). The aim is to reduce caregiver burden and/or avoid burnout.

Community IV Therapy Venous Access Algorithm

un moyen facile et pratique pour nos patients, mandataires spéciaux ou fondés de pouvoir de communiquer avec le coordonnateur de soins et le Santé à domicile Ontario.

What is Convalescent Care?
This short stay program provides 24-hour care in long-term care homes for people from hospitals or the community who need specific medical and therapy services to regain their strength, endurance and mobility. The goal is for patients to regain significant function during their time in convalescent care to return safely and comfortably to their community.

Champlain – Court séjour provisoire, Liste de choix de foyers de soins de longue durée

Email offers an easy and convenient way for our patients, their Substitute Decision Makers (SDM) or those appointed with Powers of Attorney (POA) to communicate with their Care Coordinator and Ontario Health atHome.

First Dose Parenteral Administration Screener and Medical Referral to be faxed to Ontario Health atHome (before 12pm for same day administration to be arranged) with completed information in order for first dose administration of parenteral medication to be considered:

Formulaire de demande pour la divulgation de renseignements personnels. En vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé Veuillez

L’Équipe régionale de consultation en soins palliatifs de Champlain est là pour vous appuyer.

L’Équipe régionale de consultation en soins palliatifs constitue un partenariat entre Soins continus Bruyère et Services de soutien à domicile et en milieu communautaire de Champlain. Nous représentons une équipe interprofessionnelle d’experts en soins palliatifs, y compris des infirmières praticiennes, des infirmières de pratique avancée, des infirmiers spécialisés et des médecins.

Important Note: Please follow these instructions (opens in a new tab) to access the form.
This form is to be used for completion of the assessment required under the Fixing Long-Term Care Act, 2021 when a person applies for a determination of eligibility for long-term care home admission. The required assessment is of the applicant’s physical and mental health, and the applicant’s requirements for medical treatment and health care. This assessment must be made by a physician or registered nurse.

– Patients will receive treatment in our community nursing clinics, unless under exceptional circumstances.
– We process only completed referrals (legible, signed, dated). Fax to 613.745.6984 or 1.855.450.8569.

Orders are fulfilled per Community Protocols documented on page 2, unless physician requests otherwise. We process only completed referrals (signed, dated and legible). Confidential when completed. Fax completed form to 613.745.6984 or 1.855.450.8569. If you received this form in error, please call 1.800.538.0520.

Integrated Bruyere Outpatient and Community Stroke Rehabilitation Referral Form. Complete and fax to 613-745-8243
If patient requires only a physiatry consult, please use a standard medical consultation form instead

Le programme de soins de relève de courte durée offert dans des foyers de soins de longue durée comprend des caractéristiques importantes que les participants ou leur représentant doivent comprendre. Lors de la consultation, le coordonnateur de soins suit la présente liste de vérification afin de s’assurer que le patient capable, le procureur ou le mandataire spécial comprenne bien en quoi consiste le programme.

Champlain, Liste de choix de foyers de soins de longue durée

La présente liste de vérification a pour but d’assurer que le coordonnateur de soins fournit des conseils au patient, au procureur, ou au mandataire spécial au sujet des plus importants facteurs liés au placement du patient dans un foyer de soins de longue durée. Toutes les déclarations cochées ci-dessous s’appliquent à la situation du patient.

The purpose of this checklist is to ensure the patient – or power of attorney (POA), or substitute decisionmaker (SDM) – receives counselling from our Care Coordinator about the most important factors involved in the patient’s placement in a long-term care home (LTCH). Each statement with a check mark, below, applies to the patient’s situation.

The purpose of this checklist is to ensure the patient – or power of attorney (POA), or substitute decision-maker (SDM) – receives counselling from our Care Coordinator about the most important factors involved in the patient’s placement in a long-term care home (LTCH). Each statement with a check mark beside it, below, applies to the patient’s situation.

Long-Term Care Home Crisis Choice List | Choix des foyers de soins de longue durée en cas de Crise

Champlain Long-Term Care Home Choice List

Please select up to five long-term care homes (LTCHs) for short-stay interim and rank them in order of your preference. The applicant’s name will be added to the wait lists for the chosen homes if eligible and if the chosen LTCHs can provide the required care. Ontario Health atHome will notify you about eligibility. Short-stay interim beds are available to all hospital ALC-LTC patients.

Please select up to five long-term care homes (LTCHs) for short-stay respite, including any out-of-Champlain choices and rank them in order of your preference. The applicant’s name will be added to the wait lists for the chosen homes if eligible and if the chosen LTCHs can provide the required care. Ontario Health atHome will confirm with you the availability of the requested dates.

Orders are fulfilled per Community Protocols documented on page 2, unless physician requests otherwise. We process only completed referrals
(signed, dated and legible). Confidential when completed. Fax completed form to 613.745.6984 or 1.855.450.8569. If you received this form in error,
please call 1.800.538.0520.

Up to 24 hours may be required for infusion to be initiated in the home. Incomplete prescriptions may cause delays in processing your order. Please ensure that contact information is provided so that the pharmacy can reach you should they have questions.

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.
Fax: 613-745-6984/1-855-450-8569
*Hospital: Use hospital Ontario Health atHome fax number

Le présent document a pour but d’assurer que le coordonnateur de soins fournit des conseils au patient, procureur ou mandataire spécial sur les plus importants facteurs du placement dans un foyer de soins de longue durée (FSLD). Toutes les déclarations cochées cidessous s’appliquent à la situation du patient.

Qu’est-ce que le Programme de relève et de réduction de la détresse des soignants?
Votre coordonnateur de soins a déterminé que vous êtes admissible au Programme de relève et de réduction de la détresse des soignants. Le programme prévoit un soutien supplémentaire fourni par les préposés aux services de soutien à la personne (PSSP) pour assurer un répit temporaire aux soignants, réduire le fardeau de ces derniers et/ou éviter l’épuisement professionnel.

Que sont les soins de convalescence?
Dans le cadre de ce programme de séjour de courte durée, des soins sont fournis jour et nuit dans des foyers de soins de longue durée aux personnes provenant de l’hôpital ou de la communauté qui ont besoin de services médicaux et de services de thérapie particuliers pour retrouver leurs forces, leur endurance et leur mobilité. Le but consiste à permettre aux patients de recouvrer la capacité fonctionnelle nécessaire pendant qu’ils reçoivent des soins de convalescence pour assurer leur sécurité et leur confort dans leur communauté.

Champlain Referral Form for Community Referrals

The Champlain Regional Palliative Consultation Team (RPCT) is here for you.
The RPCT is a partnership between Bruyère Continuing Care and Ontario Health atHome, Champlain area. We are a team of inter-professional palliative-care experts, including nurse practitioners, advanced practice nurses, nurse specialists and doctors.

Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004

The Short-Stay Respite in Long-Term Care Homes (SSR-LTCH) program includes important features that participants or their designate need to understand. During the required counselling, the Care Coordinator uses this checklist to ensure the capable patient (patient), Power of Attorney (POA), or Substitute Decision Maker (SDM) fully understands the program.

Veuillez choisir jusqu’à cinq foyers de soins de longue durée (FSLD) pour des soins de relève de courte durée, y compris des choix à l’extérieur de la région de Champlain, et les classer par ordre de préférence. Le nom de l’auteur de la demande sera ajouté aux listes d’attente des foyers choisis s’il elle est admissible et si les FSLD en question sont en mesure de fournir les soins requis. Santé à domicile Ontario confirmera les disponibilités des dates demandées.

Symptom Response Kit for End-of-Life Order Form – Timing and placement of the Symptom Response Kit (SRK) requires careful consideration (i.e. prognosis is less than six months; patient expected to deteriorate quickly) with goal of avoiding emergency room visit or hospital admission. Medications in the SRK will expire; therefore, will need to be reviewed and reordered by the physician/Nurse Practitioner (NP) if it remains appropriate. Consider reviewing goals of care and expected home death protocols.

Please fax to: 613.745.8243 or 1.855.450.8569

Formulaire de demande de services

Envoyez par fax au : 613 745-8243 ou 1 855 450-8569