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Service Information

Service:

Community Paramedicine Program (Health Care Providers)
Organization: Peterborough County - Paramedics
Description: If you are a Health Care Provider, you can submit a referral to help your patient stay well at home.

Community Paramedics can provide the following:
• 24/7 non-emergency contact: assessments under medical supervision or treatment of minor conditions (e.g. falls, lacerations, bruises).
• Responding to changing circumstances or medical conditions and connecting to the right health care provider/social services to avoid escalation and crisis.
• Remote patient monitoring of blood pressure, heart rate, oxygen saturation, blood glucose, weight, and/or temperature. All required equipment will be provided and the patient will be trained by the CP before using.
• Immunization, vaccination and other injections (e.g. tetanus).
• Clinical Interventions such as diagnostics (specimen collections, 12/15 lead ECGs, vital signs), immunizations, vaccinations, minor wound care, coordination of community services, observational and focussed assessments.
• Other controlled medical procedures and treatments at home under appropriate medical supervision

Please note, this program does not duplicate other referral pathways already in place within our healthcare system.

Referral Options:

Referral Urgency:*

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Referral Reason:*

Physical Assessment

Vital Signs Assessment

Home Safety Scan

Falls Risk Assessment

Medication Compliance

Chronic Disease Management

Social Isolation Risk Assessment

Other

Required: choose at least one option

If other, please specify:

This next section is based on diagnostics and remote patient monitoring. Please only select if applicable.

RPM (Performed virtually to monitor & capture medical data from the patient, submitted to CP for ax & recommendations prn):

Blood pressure

Heart rate

Oxygen saturation

Blood glucose

Weight

Temperature

Tests Required (Community Paramedics will assess Vital Signs on arrival. Please attach any documents needed to perform these tests on the next page):

Weight

Point of Care INR

12/15 ECG (not interpreted by a cardiologist)

Immunization/Vaccination

Please select all the apply to this referral:

The patient is at risk of entering long-term care or is on a long-term care waitlist.

The patient currently has a Care Coordinator with Home & Community Care Support Services (HCCSS).

The patient currently has a Family Doctor in Peterborough City/County.

Patient's living status:

Patient Information

Patient Name:

First name*

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Family/Last Name*

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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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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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Select location on a map

Sex:

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.

Patient Health Card Number:*

Patient Health Card Number*

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Version Code

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Marital Status:

Single

Married

Common Law

Separated

Divorced

Widowed

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Health Information

Reason for Referral:*

Please elaborate on the details from your selection on the first page and include goals/outcomes expected.

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Allergies:

Please list and describe any allergies

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Medications:

List all medication, and dosages per day

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Relevant Medical History:*

Number of hospital admissions past year, Communicable diseases, sensory/mobility impairments (mobility/hearing aids, corrective lenses, etc.), cognitive/communicative impairments (type, presentation, communication aids), history of delirium (date/location of last diagnosed incident) and other relevant medical details.

This field is required

Additional Information

Please list all known community/health support and services the patient is currently receiving:

Are there any known safety concerns associated with the paramedic entering the patient's home?:

Please include any other pertinent details or instructions related to this home visit from the Community Paramedics.:

Does the referrer require OTN or phone consultation before/after the visit?:

If yes, please provide your OTN account email and or the best phone number to called at and if it is before/after::

If you are not the patient's Primary Care Provider (Physician or Nurse Practitioner), and they have one, please include their full name and office fax number:

All results/outcomes will be sent back to the referring provider via Caredove if you have an account:

If you submitted with no portal login, please include your name, title, place of work relevant to this patient, the best phone number to reach you about this referral prn and fax number to send outcomes to.:

Documentation:

Please ensure you attach all relevant requisitions to this referral.
If you are having difficulties uploading, please send us a fax at 705-745-1784 (for requisitions and relevant documents only, please).

Add files

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

Yes

Consent

Does the patient or caregiver grant 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 Peterborough County - Paramedics online.

You agree to these Terms and Conditions and Privacy Policy, which govern how your personal information is kept safe.

Notifications:

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

Yes

To receive notifications, please select Yes.

Submission complete

The information has been submitted to Peterborough County - Paramedics, but you have some steps left:

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Summary

Reference #: -

Registrant:
Organization:

Peterborough County - Paramedics

Service:

Community Paramedicine Program (Health Care Providers)

Inquiry Phone:

1 (705) 743-5263

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

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