South East 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.

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.

Fax: 613-650-2996
*Hospital: Use hospital Ontario Health atHome fax number

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.

To order care relating to Home Parenteral Nutrition in the South East. NOTE: Two (2) business days notice required

Patients enrolled in the COVID-19 Remote Monitoring Program use an app on their smartphone to report their symptoms to their nurse.

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

Referral form for administering COVID-19 antivirals in South East community nursing clinics.

Mental Health & Addiction (MHAN) Nurse Referral. Please fax to: 1-613-650-2992

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

Continuous Ambulatory Delivery Device Patient Controlled Analgesia Prescription Order.
Fax completed CADD Prescription/Order forms to Ontario Health atHome at 1-866-839-7299

South East Medical Assistance in Dying Assessment Record, Please ensure form is completed and uploaded to patient’s CHRIS file.

South East Medical Assistance in Dying Procedural Record

For help to complete the form, please call Ontario Health atHome’s central access team at 1-800-869-8828 ext. 4003.

NOTE: Referral processing cannot be initiated unless page 1 of form is complete. Referring physician will be notified re missing & required information as soon as noted, in order to prevent delay in service arrangements.

By completing this form, the prescriber confirms that all safeguards have been met for the patient to be eligible to receive MAID.
Please ensure form is completed for accuracy. Once completed fax to 1-888-334-6559.

Home and Community Care Support Services South East Medical Order Form

Palliative Care SBAR Communication Tool for Nurses in the South East

Ontario Health atHome, South East area service request/referral form

Ontario Health atHome – South East referrals from hospital

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