Complete and Fax to: (519) 292-2135; Refer to Coordinated Care Planning Checklist for Details
COORDINATED CARE PLANNING COMMUNICATION TOOL
Patient Demographics:
Name: ______DOB:______Phone number ______LHIN ID #______
When any provideridentifies a complex patient with high care needs who may benefit from Health Links Coordinated Care Planning (HL CCP), please discuss the option of Coordinated Care Planning with the patient. If the patient would like to proceed, discuss the patient’s needs with their care providers (primary care, CCAC, CSS, Mental Health and Addictions Supports, etc.). The purpose of this page is to capture how the potential patient is being identified and reasons for which Coordinated Care Planning may not proceed. This page is to be completed by the member of the care team who identifies the potential patient,as soon as the decision has been made to proceed or not proceed with Coordinated Care Planning.
Patient Identified by:
RIDS (Hospital Utilization List) CCAC CSS Hospital Inpatient Hospital ED
Primary Care Provider Other: ______
Referral Source:
Person filling out form (print): ______
Signature: ______
Organization Name: ______
Physician (name):______Physician contacted: Yes No
Coordinated Care Plan Will BeInitiated: Yes No Date (MM/DD/YYYY): ______
*if No, please provide the reason below:
Patient declined: reason: ______
Provider(s) declined: reason: ______
Alternative level of support more appropriate: explain:______
Patient deceased
Other reason: ______
Fax this page to (519) 292-2135if Coordinated Care Plan is declined
Date of initial Lead Navigator meeting with patient (DD/MM/YYYY): ______
The purpose of this page is to communicate key details of the scheduled Care Conference to all attendees. This page is to be completed by the Lead Navigator/Administrative Logistical Support prior to the conference.
Pre-Conference Meeting Detail:
Date:______Teleconference # (if needed): ______Start time:______End Time:______
Lead Navigator/Conference Facilitator (please print) ______
Care Conference Meeting Details:
Date:______Start time:______End Time:______Location: ______
Lead Navigator/Conference Facilitator: ______
Primary Reason for Conference: ______
Type of Conference New Conference Follow-Up Conference
Please complete the following chart:
Attendee name & title / Phone number / Fax number / Notified of Conference? / Received draft HL CCP? / Attended Conference? / Received finalHL CCP?Primary Care Physician:
CCAC: / 1-844- 222-2463 / 519-276-3393
Community Support: / 519-482-1634 ext 2002 (Patti Rosehart) / 519-482-1498
Other Role/Profession/Caregiver:
Other Role/Profession/Caregiver:
Other Role/Profession/Caregiver:
Forward this page to all attendees approx. 1 week before the Coordinated Care Planning Conference
The purpose of this page is to collect feedback from patients/family/supports and providers following the Coordinated Care Planning Conference. This page is to be completed by the Lead Navigator at the end of the conference and during the immediate post-conference de-brief.
FEEDBACK:
1)Patient Feedback: How confident was the patient that the identified goals will be achieved?
1 2 3 4 5
Not at all confident Very confident
2)Patient/family/caregiver consents to future Interview to discuss their experience: Yes No
Note: If yes, Lead Navigator to contact:
Shirley Koch
Regional Manager, Strategic Planning and Integration, South West Community Care Access Centre
1.800.269.3683 X5984 Fax: 519.273.2139 Email:
Suggestions/Feedback from Patient/Family/Supports: ______
3)Provider Feedback: How satisfied were you with the Coordinated Care Planning Process? (record the average of all providers)
1 2 3 4 5
Not at all satisfied Very satisfied
Suggestions/Feedback from Providers:______
This purpose of this page is to capture further feedback from the patient. This page is to be completed by the Lead Navigator during the 2 week post conference check-in with the patient.
1)How confident was the patient that the identified goals will be achieved?
1 2 3 4 5
Not at all confident Very confident
2) Did the patient feel respected?
1 2 3 4 5
Not at all respected Very respected
3)Did the patient feel supported?
1 2 3 4 5
Not at all supported Very supported
Suggestions/Feedback: ______
Fax pages 1-4 to (519) 292-2135after the 2 week post conference check-in with the patient
Patient has died on (date MM/DD/YYYY): ______
Fax this page to (519) 292-2135if patient has died
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Last UpdatedSeptember 14, 2015