Home Care Referral and Transfer

Home care services are ordered by providers in Connect Care and managed by Continuing Care Access services with the aid of Connect Care. In most cases, referrals are initiated by transition coordinator, care manager or nursing staff in keeping with decisions made at interdisciplinary team rounds. Prescribers may need to co-sign some referral orders. They may need to enter and sign service orders when specific medical interventions are required.

Acute Care

The intended home care services are fulfilled outside the current inpatient admission. Consequently these orders are not available in the inpatient orders catalogue. They must be entered as "external orders" via a tab within the Orders activity in an inpatient encounter. If proximate to discharge, they can be entered within the Discharge Orders portion of the Discharge Navigator.

Ambulatory Care

Orders for home care referral and service are available within the outpatient orders catalogue, always accessible at the bottom of the Hyperspace screen, and part of the Plan activity.

Once the desired order is found and initiated, the ordering process is the same for acute and ambulatory care. If similar orders are commonly issued, save instances of the order(s) as favourites so repeat workflows are faster.

Home Care Referral Order

A home care referral order initiates the process for matching services to needs. It is usually placed by nursing, with possible prescriber co-signature.

  • For a new referral to home care, enter “Home Care” in the Orders activity search box, choose the "Home Care Orders" panel, then find the “Ambulatory Referral to Continuing Care Access” order. If the Home Care Orders panel does not appear, check the “Facility List" tab.

  • A tip indicates the fields that need completion in the order composer.

  • Upon signing the order, it will appear in the Medications & Orders section of the outpatient encounter Plan activity, or the External Orders tab for inpatient, where it can be deleted if needed.

If a patient has already been referred and/or is currently receiving home care/supportive living services, an update note for the case manager is needed rather than a referral order (see Tip: Update Home Care or Supportive Living Case Manager).

Home Care Service Order

A home care service order is needed when specific medication, medical or professional service instructions must be relayed for post-discharge home care attention.

  • Enter “Home Care” in the Orders activity search box, choose the "Home Care Orders" panel, then seek the desired home care service. If the Home Care Orders panel does not appear, check the “Facility List" tab.

  • Each home care service order should be placed individually in the order composer. Enter instructions in the "Comments" field by adjusting the prepopulated SmartText (see tip). Possibly also enter additional scheduling or duration information in the "Sched Inst" field.

      • If more than one home care service order was selected, a “Duplicate Orders Found” window will appear. Verify that the orders are different.

  • If a patient is currently receiving home care/supportive living services, an update note for the case manager is needed in addition to the home care service order (see Tip: Update Home Care or Supportive Living Case Manager).

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