Home Care Referral and Service Orders

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 a transition coordinator, care manager or nursing staff in keeping with decisions made at interdisciplinary team rounds. Prescribers can place home care orders and may need to co-sign orders placed by others. Workflows are the same for emergency, inpatient and outpatient contexts. 

General home care workflows are described in this section. A tip highlights how a patient's current Community Services status can be viewed by prescribers working with patient charts in inpatient, outpatient and emergency contexts:

Acute Care

Home care referrals and orders are all handled within a "Home Care Orders" order set, easily found by searching for "Home Care" in the Orders activity. The same orderset can be accessed from within the Discharge Orders activity (linked from the discharge navigator).

Clinicians were previously directed to enter Home Care orders as "external orders". This is no longer necessary.

Ambulatory Care

Home care referrals and orders are handled within an integrated "Home Care Orders" SmartSet (identical to the one used in emergency or inpatient contexts), found via the usual orders lookup tool (always available at the bottom of an opened chart) within outpatient workflows. Order access is also prominent in the outpatient encounter "Plan" activity and in the "SmartSets" section.

Emergency Care

Emergency providers arranging community care for patients discharged from the emergency department should file home care referrals and orders using the integrated "Home Care Orders" SmartSet (identical to the one used in other contexts). This is found in the "Discharge Templates" section of the "Dispo" (Disposition) navigator. Use the search tool to seek "Home Care".

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

Home Care Order (Smart) Set

Once the desired order set (inpatient) or Smart Set (outpatient and emergency) is found and initiated, the ordering process is the same for emergency, acute and ambulatory care. If similar orders are commonly issued, save instances of the order set as personalized favourites so repeat workflows are faster.

Home care referrals consist of two distinct ordering actions, placing a request for services and specifying the exact interventions requested of home care providers. Both actions are integrated in the "Home Care  Orders" order set.

Home Care Referral 

A home care referral order initiates the process for matching services to needs. As explained in the order (Smart) set instructions, new referral orders are not needed for patients already enrolled (pre-admission) and receiving home care services. The focus for established home care clients  is on the home care service order(s), clarifying what may have changed in a patient's needs. 

A home care service request is initiated with the "Referral to Home Care" section in the order (Smart) set. Open this and select the "Ambulatory Care Referral to Continuing Care Access and Home Care", then provide as much detail about the request as possible by answering the questions embedded in the order:

A prescriber tip sheet illustrates the workflow:

Home Care Service Order(s)

All home care must contain one or more home care service order(s), even if these are a continuation of pre-admission home care interventions. This provides specific instruction about  medication, medical or professional services that must be relayed to home care service providers. 

A prescriber tip sheet illustrates the workflow:

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