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.

  • Enter “Home Care” in the order search box to find the “Ambulatory Referral to Continuing Care Access” order. If this does not appear, click on the “facility tab” to reveal the order.

  • The order composer has many options, but only four typically need attention. Be sure to enter a short reason for referral (e.g., "wound care and re-activation") and to answer all questions appearing in the Comments field (see tip).

  • 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 home care service orders are required (e.g., wound care instructions), these should be set up before entering the home care referral order, as the service order(s) is referenced within the referral order.

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 order search box to seek the “Home Care Patient Care Order”. If this does not appear, click on the “facility tab” to reveal the order.

  • The order composer is very simple, with just two free-text fields. Be sure to enter all instructions (avoid multiple services orders) in the Comments field, and possibly enter additional scheduling or duration information in the "Sched Inst" field (see tip).

  • A number of SmartText templates are available to help prescribers enter complete and actionable home care service orders. Find these by using "HCO" as a search term in the SmartText lookup box.