Waterloo Wellington 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

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

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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.

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.

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

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

Form 550 B – Fax Completed form to 519-742-0635

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.

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: 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.

Ontario Health atHome Child and Youth Mental Health & Addictions Nursing Program
Fax: 1 (519) 571-3957
A mental health nurse will connect with student, parent and/or guardian to confirm consent and finalize eligibility.

Completed by a Primary Care Physician or Registered Dietician

Completed by Retirement Home(RH) or HCCSS staff to outline services that a patient is currently receiving or may require if moving to a Retirement Home setting

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).

Form 550A – Fax completed form to 519-742-0635
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.

Form 552, Notification of Rehabilitative Care, Palliative Care, Transitional Care or Residential Hospice Bed Vacancy

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

Completed by Retirement Home staff when requesting a Swallowing Assessment

Completed by a Primary Care Physician

Request for Hospice Palliative Care Services – Form 031B, Completed by a Primary Care Physician

Completed by Primary care Physician to request Home Care services. Patient/Families may also print this referral form to bring to an appointment for completion.
If initiating referral for HPC services, please use Form 031B, “Request for Hospice Palliative Care Services”