Document Category: Coordinated Bed Access

Confirmation of medical stability and program readiness
Inpatient rehabilitative care and other complex continuing care
Do NOT use this application for Palliative care referrals.

Fax form to CBA team at 519-742-0635

Highland Retirement Home
20 Fieldgate St, Kitchener, ON

Stone Lodge Retirement Residence
165 Cole Rd, Guelph, ON

FAX COMPLETED FORM TO Ontario Health atHome: 519-742-0635
How is Crisis defined?
A patient is considered to be “In Crisis” if:
1. Patient and/or caregiver safety is at risk and/or there is a risk that a significant health event and/or challenging end-of-life symptoms cannot be managed in their current setting
2. Patient at risk of requiring ED or acute care admission
3. Community resources have been exhausted and family/ caregivers are unable to cope with the patient’s care needs
4. There is a risk that the services required to meet the patient’s end-of-life care plan goals may not be available in their current setting
5. Patient at risk of not accessing their preferred place of death (considering recent trajectory of the PPS score).

Coordinated Bed Access referrals are coordinated by Ontario Health atHome WW. The Hospital will be sharing your medical and personal information with Ontario Health atHome WW. Ontario Health atHome WW will add your name to the waiting list. Your initials and gender will be accessible to Ontario Health atHome WW’s other hospital partners. The hospital and Ontario Health atHome WW will share your medical and personal information with the Rehabilitation program.

Completed by a Coordinated Bed Access Coordinator (Ontario Health atHome staff) for transfers in the rehab bed program.
Please fax completed form and updated letter of understanding to Ontario Health atHome (519) 742-0635
For Neurobehavioural and Geriatric Assessment Units fax to (519) 749-4326

* Note: Medical conditions must be stable, managed in an RN/RPN scope, not require daily MD assessment.

*Patients requiring palliative care can be admitted from any sending facility in the system, including Home (admissions from LTC will be considered on a case-by-case basis after a palliative pain an symptom managing consult is completed).

Inpatient rehabilitative care is the next step in your recovery. It will help you work towards regaining your strength and independence. It will also help you with returning to your usual activities as much as possible.

* Note – medical conditions must be stable, managed in an RN/RPN scope, not require daily MD assessment.

* Note – medical conditions must be stable, managed in an RN/RPN scope, not require daily MD assessment

Acute Care to Rehab & Complex Continuing Care (CCC) Referral
Referrals are coordinated by Ontario Health atHome Waterloo Wellington. Your health care team will be sharing your
medical and personal information with Ontario Health atHome WW and the rehabilitative care program. Ontario Health
atHome WW will add your name to the waiting list. Your initials and gender will be accessible to Ontario Health atHome
WW’s other hospital partners
Fax Completed Form to 519-742-0635

Patient information for Inpatient Rehabilitative care to outline the next step in recovery. The rehab program will work toward regaining a patient’s strength and independence.

Provides guidelines for any individual meeting eligibility for the Hospice Residential Program for End of Life Care.

The Palliative Care Program provides a range of palliative care to meet the needs of patients with both oncological and non-oncological care needs which include pain and symptom management through to end of life care. Patients requiring palliative care can be admitted from any sending facility in the system, including home.

Form used by HCCS staff to outline Medical Procedures, Medical Professionals and Special Equipment that is available.