Région de Hamilton Niagara Haldimand Brant

Referral Form to request the palliative care outreach services in Brant.

Complete the Burlington IPCOT referral form and fax supporting documents to: 905-631-6823
– Medical summary/ health history
– Pertinent diagnostic tests
– Current medication lists
– Pharmacy information
– Consult/ progress notes
– Other notes

To order the administration of ceftriaxone to patients being discharged from the Brantford Community Healthcare System (BCHS)

Paramedic Services will communicate back to Home and Community Care Support Services using the HNHB Community Paramedicine Communication Form.

To order first dose IV medications to be administered to patients in the community. First dose requests may take longer to process and are not appropriate for urgent requirements.

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

To request the services of the Palliative Care Outreach Teams in Haldimand Norfolk

To request the services of the Palliative Care Outreach Team in Hamilton

To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital

To refer a patient to (apply for) hospice and hospice-type services

For hospital partners who use Health Partner Gateway to receive patient referrals.

To order administration of influenza vaccine

Information sheet for patients and families.

Hamilton Niagara Haldimand Brant, Iron Infusion order form – To order intravenous iron replacement

To identify who will complete pronouncement and certification of death for an expected death at home

For Long-Term Care Partners in HNHB. 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

To be completed and signed by an HCCSS Care Coordinator to refer a patient to Margaret’s Place for Palliative Overnight Respite care

To order general medications, including wound care and maintenance for urinary catheters

To order from HNHB’s medical supplies catalogue

To order from HNHB’s medical supplies catalogue

Mental Health and Addictions Nursing Program Referral Form.

To request the services of the Mental Health & Additions Nurse, the patient must be:

1. A student registered in school and who is no older than 21 years of age (may include home instruction)
2. In need of services or related treatment to an identified and/or suspected mental health and/or addictions issue
3. Aware of and consenting to the referral

Additionally, there must be a clearly defined role for the Mental Health & Addictions Nurse

To order midline catheter maintenance

To order Milrinone Infusion Therapy for adult patients

Note: This form will be effective on July 23, 2024.

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.

The Niagara Palliative Care Outreach Team (PCOT) is a group of specialists, including Nurse Practitioners, Palliative Care Clinician, Navigator and Psychosocial Counsellors.
The services available are:

• Complex pain & symptom management support for end-of-life issues
• Psychosocial-spiritual support, including bereavement follow-up
• Mentorship & coaching

Nursing Care Centre locations throughout HNHB geography.

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. Note: See Palliative Care Symptom Response Guidelines for more info on how to use the form.

Guidelines how to use the Palliative Symptom Response Order Form.

To order Milrinone Infusion Therapy for pediatric patients

To clearly communicate a patient’s plan of care relating to the provision of CPR.

To order care relating to vascular access devices in children

To order care relating to vascular access devices in adults (in accordance with the Vascular Access Maintenance Protocol)

To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for adult patients

Complete the Request for Ontario Health atHome, Hamilton Niagara Haldimand Brant area, services 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.

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

For patients being discharged home from hospital with a new tracheostomy and laryngectomy care for patients being discharged home from hospital

To order IV vancomycin and/or aminoglycosides for patients in the community