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Service Information

Service:

Community Paramedicine Program - Healthcare Providers
Organization: Peterborough County - Paramedics
Description:

Please note that the processing time will be approximately 4 weeks as we are receiving high referral rates at this moment. Referrals will be looked over for eligibility.

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 for those with chronic condition, enrolment to be determined by paramedic. (All required equipment will be provided and the patient will be trained by the CP before using.)
- Immunization, vaccination and other injections for homebound patients (COVID, Pneumovax, Influenza, Shingrix).
- Clinical Interventions such as diagnostics (12/15 lead ECGs, vital signs), minor wound care, coordination of community services, observational and focused assessments.
- Point of care urinalysis (excluding urine culture) and blood tests (homebound clients) including: A1C, INR, pH, pCO2, pO2, TCO2, Na+, K+, Ca++, Cl-, Hct, Glu, Lac, Crea, BUN, and Urea. Currently, we do NOT offer CBC testing. - 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 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):

Point of Care INR

12/15 ECG (not interpreted by a cardiologist)

Immunization/Vaccination

Please select all that 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:

Eligibility:*

Are these eligibility requirements met?

The patient is at risk and/or is on the list for entering long-term care facilities.

Yes

No/Unsure

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

This field is required

This patient have multiple chronic conditions that are not managed well and are at risk for hospitalization.

Yes

No/Unsure

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

This field is required

Patient Information

Patient Name:

First name*

This field is required

Family/Last Name*

This field is required

Email Address:

This field is required

Phone:

Primary Phone*

This field is required

Address:

Unit/Suite #

This field is required

Street # & Street Name*

This field is required

City*

This field is required

Province/State*

This field is required

Postal/Zip Code*

This field is required

Select location on a map

Sex:

Male

Female

Other

This field is required

Date of Birth:*

Day

Month

Year

Age: ( corrected)

This field is required

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*

This field is required

Version Code

This field is required

Marital Status:

Single

Married

Common Law

Separated

Divorced

Widowed

This field is required

Family Doctor:

Family Doctor Name

This field is required

Family Doctor Phone #

This field is required

Caregiver / Emergency Contact

Relationship to Patient:

Spouse

Son/Daughter

Sibling

Parent

Friend

Legal Guardian

Other

This field is required

Caregiver / Emergency Contact Name:

First name

This field is required

Family/Last Name

This field is required

Caregiver / Emergency Contact Info:

Primary Phone

This field is required

Health Information

Reason for Referral:*

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

This field is required

Allergies:

Please list and describe any allergies

This field is required

Medications:

List all medication, and dosages per day

This field is required

Relevant Medical History:*

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), other relevant medical details

This field is required

Additional Information

Current Services:

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

Primary Care Provider Information:

If you are not the patient's Primary Care Provider and they have one, please include their full name and office fax #:

Name of HCCSS Care Coordinator:

Referring Party Name:*

This field is required

Referring Party Title & Workplace:

Referring Party Phone #:

Referring Party Fax #:

Documentation:

Please ensure you attach all relevant requisitions to this referral.

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

This field is required

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Summary

Reference #: -

Registrant:
Organization:

Peterborough County - Paramedics

Service:

Community Paramedicine Program - Healthcare Providers

Inquiry Phone:

1 (855) 367-3670

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

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