Intake Form: Traditional Healing in Hospice Palliative and Bereavement Support

Date of referral______Referred by______Agency______

Date at End of Service______

DEMOGRAPHICS

Name______Age______Sex: M__ F__ LGBTQ__ Other___

Aboriginal Number/Clan______

Address:______City/Town______Postal code______

Who is your support person(s)? (contact information)______

Why are you seeking support? ______

SUPPORT REQUEST

Request: Palliative ___ Bereavement ___Transportation ___ Pre approval letter to NHIB dated/sent_____

Traditional Healing:Elder___ Healer___ Ceremonies _____Drumming/ smudging____ Other____

Current Supports:Traditional Healing ______LHIN CC _____Hospice Residence ___Volunteers ___ Other ______

Request: (Urgent/Non urgent)Elder ___Healer___ Ceremonies (describe)______

Appointment Date/Time: ______Location of service: Home____ CHC_____ Other ______

OFFICE ADMINISTRATION

Scanned Referral to Hospice (att. Pat Stuart to confirm client candidate for end of life or bereavement support)

Date______Time______

CHC Approval:Approved____Not approved (reason)______

Referrals to other resources______

SIGNATURES

CHC signature______CHC Position______

Hospice Wellington ______(scan back to Jennifer Antler CHC when signed)

TRADITIONAL HEALING: HOSPICE PALLIATIVE AND BEREAVEMENT

Referral Process

Referral Process

  • Guelph CHC receives direct referrals at 519-821-6638 #321, Monday to Friday 0900 to 1600 hrs, excluding holidays.
  • After hours the phone extension goes to answering machine to record requests for referral or assistance.
  • CHC Web site will be updated with details of Traditional Healing opportunities effective February 26, 2018.

Approval or Non approval

  • Referrals are processed and approved within 48 hrs unless urgent which is 24 hrs from receipt of call.
  • CHC completes the Traditional Healing Referral form, signs and approves, then scans to Hospice Wellington (Pat Stuart or designate) at Hospice Wellington.
  • Hospice Wellington reviews and approves as a Palliative or Bereavement client and scans back to CHC for activation.
  • CHC develops a confidential file to maintain updated entries and information for monthly report.

Activation

  • CHC calls appropriate Traditional Healers and matches availability to that of the client, confirming with both parties.
  • CHC prepares/sends NHIB preauthorization letter for Transportation requests
  • CHC documents Healer information issues both on client file and monthly data sheet

Quality Improvement

Clients, either family caregivers or individuals themselves.Families who have lost a loved one and/or Bereaved clients, will be phoned and asked to respond to a Satisfaction survey within 6-12 months post service or as appropriate, for future quality improvement opportunities

Monthly and YTD data

  • CHC prepares monthly and/or YTD report which is distributed to CHC and Hospice Wellington
  • Monthly report includes reimbursement amounts and processing