Inpatient Hospice Palliative Care Directory Facility Update Form

Transcription

1 Inpatient Hospice Palliative Care Directory Facility Update Form Please complete the following form to add a new facility or update your facility details. Complete the form in its entirety. Save and send via to ontariohpc@uhnresearch.ca. Facility Name Address City Province Postal Code Primary Phone Fax Number Community Care Access Centre District Central Does your facility have a Catchment Area? Care Offered In Patient Services Acute care Community hospice visiting home support Day hospice program Inpatient palliative care consult service Long term care Outpatient pain clinic Palliative care outpatient clinic Palliative community outreach team Referrals to palliative community outreach team Referrals to residential hospice and palliative care units

2 How many designated Hospice/Palliative Care beds does your facility have? Length of Stay Doctor Referral Required? Does your facility require Pre- Admission Documentation? Documents Required N/A Application Bloodwork C-Diff status CCAC referral CT report Common referral form Consults ESAS General patient information Medical history Medication list MRI report MRSA results Palliative assessment Palliative care consult Palliative care referral form Patient history Physical PPS score Referral form Referral form from University Health Network Palliative Care Team Relevant consults Relevant diagnostics Signed consent VRE results X-ray report Maximum Age Requirement

3 Minimum Age Requirement Diagnosis Required? DNR Required? Prognosis Required? Reason For Referral (check all that Medical Needs Accommodated Complex psychosocial support End of life care Pain and symptom management Perinatal hospice care Respite for family Respite for patient Transition to home Transition to longer-term palliative placement ARO+ Bipap C. Diff CADD pump Chest tube(s) Colostomy Cpap Dialysis Disseminated shingles Feeding tube Hickman line(s) Hypodermaclysis (offered on case by case basis) Ileostomy Infection control Infusors Intraspinal Analgesia Intrathecal pain management IV antibiotics IV chemotherapy IV hydration Medical needs that are accommodated through CCAC Methadone for pain management MRSA+ Nephrostomy tube(s) Oral chemotherapy Oxygen Palliative radiation

4 Paracentesis PICC line Portacath Special mattresses Suctioning Thoracentesis TPN Tracheostomy Transfusions for symptom management Ventilator VRE+ Wound Care Number of Wards Number of Semi- Private Rooms Number of Private Rooms Co-Payment Leave Of Absence Duration Staff Support Addiction Consultant Advance Practice Nurse Anesthetist Art Therapist CCAC Support Child Life Specialist Clinical Nurse Specialist Ethicist Family Physician General Surgeon Geriatric Psychiatrist Geriatrician Hospitalist Infectious Disease Consultant Internist Massage Therapist Medical Oncologist Music Therapist Occupational Therapist

5 Palliative Care Resource Nurse Palliative Physician Patient Care Manager Personal Support Worker Pharmacist Physiotherapist Psychiatrist Psychologist Radiation Oncologist Recreational Therapist Registered Dietician Registered Nurse Registered Practical Nurse Rehab Assistant Respiratory Therapist Social Worker Speech Language Pathologist Spiritual Care Advisor Surgical Oncologist Utilization Specialist Volunteer Support Programs Available (check all that N/A Access to Ontario Telemedicine Network Psychiatry Acupuncture Art Therapy Chiropractic Group counseling Horticultural Therapy Individual counseling Journalling Massage Therapy Music Therapy Pet Therapy Quilting/Needlepoint Recreational Therapy Referrals to Community Support Reiki Relaxation/Meditation Substance abuse counseling Therapeutic touch Yoga

6 Bereavement Services Available Group counseling Individual counseling Referral to existing community bereavement supports Memorial services to honour residents/patients and support family Volunteer patient family support group Cost Associated With Room