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Service Information

Service:

Regional Integrated Care
Organization: South-East Ottawa Community Health Centre
Description:

Coordinating all the services and supports that a person with multiple health conditions requires. The client will be assigned a care coordinator and work with them to identify the care team members and to develop a coordinated care plan that focuses on the client’s goals. Anyone – a family doctor, care provider, friend, family, caregiver or even a client - can identify someone who fits the criteria.

Referral Options:

Which 4+ chronic conditions does the client have? (at least one is a physical health condition):*

Amputations

Cancer

Chronic pain

Dementia

Developmental disability

Diabetes

Frailty

Heart disease

HIV/AIDS

Hypertension

Kidney disease

Liver disease

Lung disease

Neurological disorder

Mental health

Palliative

Substance abuse

Other

Required: choose at least one option

If other, please specify:

Which social determinants of health is the client experiencing? (at least one is required):*

Lives alone/isolated

No social supports

Risks for general safety

Recent immigration

Abuse (past, present)

Food insecurity

Unemployment

Low individual income

Housing concerns

Other

Required: choose at least one option

If other, please specify:

Important considerations:

At risk of imminent decline

Frequent ED visits

Frequent Primary Care appointments

Frequent hospitalizations

Frequent missed appointments

Frequent use of crisis services

Eligibility:*

Are these eligibility requirements met?

Client has 4 or more complex health conditions (at least one being a physical health condition) for example: heart disease, lung disease, diabetes, mental illness.

Yes

No/Unsure

Warning: Submission may be denied, please provide more details.

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Client has at least 1 social determinant of health issue (e.g., poverty, housing) or is receiving health services from many different professionals /organizations.

Yes

No/Unsure

Warning: Submission may be denied, please provide more details.

This field is required

Client Information

Client Name:

First name*

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Family/Last Name*

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Personal Pronouns:

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Email Address:

Email (Confirmation and reminder emails will be sent here)

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Phone:

Primary Phone*

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Secondary Phone

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Address:

Unit/Suite #

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Street # & Street Name*

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City*

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Province/State

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Postal/Zip Code

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Gender:

Male

Female

Undisclosed/Other

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Date of Birth:

Day

Month

Year

Age: ( corrected)

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Ineligible - You have specified age of .

The age eligibility requirements for this service is:

Warning: Submission may be denied.

Client Health Card Number:

Client Health Card Number

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Version Code

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Language:

What is the preferred Language?

English

French

Other

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Is an interpreter required?

Yes

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Conduct Appointment With:

Client

Alternate Contact

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Alternate Contact

Relationship to Client:

Spouse

Son/Daughter

Sibling

Parent

Other

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Alternate Contact Name:

First name

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Family/Last Name

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Alternate Contact Email Address:

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Alternate Contact Info:

Same contact information as Client

Primary Phone

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Secondary Phone

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Health Information

Diagnosis:

Primary Diagnosis

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Reason for Referral:

e.g., New Diagnosis, Recent hospital admission, Caregiver burnout, etc..*

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Additional Information

Please describe other services client currently has access to:

Does the client have a Primary Health Care Provider (e.g., MD or NP)?:*

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Primary Healthcare Provider's name, phone # and fax #:*

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Referral source:*

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Referral source contact info:

Documentation:

Attach additional documentation as needed (e.g. Discharge Summary)

Add files

Are you sending any additional documentation separately by a method other than online through Caredove (e.g, via fax)?

Yes

Consent

The client is aware of this referral and has granted consent to send this referral.

Yes

This must be to continue

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By clicking "Finish", you agree to send this personal information to South-East Ottawa Community Health Centre online.

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Notifications:

Send confirmation, change & reminder messages to < name > < email >

Yes

To receive notifications, please select Yes.

Submission complete

The information has been submitted to South-East Ottawa Community Health Centre, but you have some steps left:

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Summary

Reference #: -

Registrant:
Organization:

South-East Ottawa Community Health Centre

Service:

Regional Integrated Care

Inquiry Phone:

1 (613) 745-8124

Tip: Referrals can be viewed by navigating to referrals in the top menu

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