Hamilton Niagara Haldimand Brant area

*Requests are only for Hospital to Home (H2H) patients already being supported by H2H program within the community
**Hospital based patients are to be initiated as per hospital Ontario Health atHome processes
Please fax completed form to Ontario Health atHome H2H ODB team at 1-877-546-4311

Nursing services are primarily provided in clinics, with in-home care only by exception. Prescribers must ensure therapy is appropriate and safe; first dose requests may take longer and are at the nursing provider’s discretion. Patients receive self-management teaching and follow-up, and services are not duplicated. Ineligible medications include blood products, naturopathic, and experimental treatments.

For Adults 18 years +
First dose requests may take longer to process and the decision to administer the first dose parenteral medication is made by the Service Provider.

Pediatric Patients at McMaster Children’s Hospital (MCH) Hamilton
Toll Free Phone Number: 1-800-810-0000

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

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.

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.

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

To order midline catheter maintenance

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

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.

To order administration of influenza vaccine

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

Complete the Burlington IPCOT referral form and fax supporting documents to: 905-574-6335
– Medical summary/ health history
– Pertinent diagnostic tests
– Current medication lists
– Pharmacy information
– Consult/ progress notes
– Other notes

To order Milrinone Infusion Therapy for adult patients

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

Serving the Haldimand, Norfolk, Brant, Brantford, Six Nations and Mississaugas of the Credit First Nations
For Stedman & Six Nations Outreach Team (all areas) – Fax: 519-751-7527
For OHaH Nurse Practitioners (Haldimand and Norfolk areas only) – Fax: 1-833-305-1947
For Norfolk Haldimand Community Hospice – Fax: 519-751-7527

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.

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

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 for teaching of IV Administration
• 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 Milrinone Infusion Therapy for pediatric patients

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

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

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

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.

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

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

Information sheet for patients and families.

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

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

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

Nursing Care Centre locations throughout HNHB geography.

Fax completed form to 1-866-655-6402
Note –If patient is receiving treatment through Ontario Health atHome the medication will be provided to the patient through Calea. Do not have patient pick the medication up from their own pharmacy.

Guidelines how to use the Palliative Symptom Response Order Form.

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

To order care relating to the Protocol for Home Parenteral Nutrition (PPN or TPN) for pediatric patients at McMaster Children’s Hospital. Contact HNHB at 1-800-810-0000