Referral form
Home and Community Care Referral
In Ontario, Home and Community Care Support Services (HCCSS) — still called 'the LHIN' or CCAC in many clinics — triages home nursing, PSW, physiotherapy, occupational therapy, and related services. The referral is how you describe what has to happen in the house, not a request for 'more help' with no hours or no safety information.
What care coordinators need
Use the current regional referral. Names of the organizations have changed; the job has not. They need the patient's location, a working phone, a clinical reason for home care rather than clinic care, and which services you think are required.
A post-stroke patient who cannot climb the stairs to the only bathroom is an OT and PSW story. A well patient whose daughter wants a weekly bath because it would be nicer is not. Write function and risk.
Safety is not optional small print
Weapons, aggressive pets, smoking with oxygen, bedbugs, and a partner who will not let staff in are reasons visits fail. Put them on the referral. Surprising a nurse is how the first visit is refused.
Who refers
Physicians, NPs, hospital teams, and others the current form lists. A family member can call HCCSS, but a clinician referral with diagnoses and wound or therapy detail is what gets a service authorization rather than a general intake.
How to complete the referral
- Identity, address, phone, substitute decision-maker if any.
- Why home, not clinic: mobility, cognition, infection control, palliative, new device.
- Services: nursing (wound, IV, Foley), PSW (which ADLs, how many people to transfer), PT, OT, speech, dietitian, social work — only those you mean.
- Transfer status: independent, one-person, two-person, lift. Weight if known.
- Cognition and whether the person can be left between visits.
- Follow-up clinician who will take calls when the wound is worse on day three.
- Urgency: same day vs routine. Same-day needs a reason (new Foley, unstable palliative, hospital discharge today).
Worked example (fictional)
Post-stroke discharge — home PT/OT/PSW
Fictional 79-year-old. Do not copy onto a real HCCSS referral.
Discharged 27 Aug 2026 after left MCA infarct. Lives in a bungalow with spouse, one step at entry, bathroom on the same floor. Function: walks 8 m with a 4-wheel walker, supervision. Transfers: one-person stand-by. Right arm flaccid, cannot dress upper body independently. Continent. Swallow: minced, thin fluids, no current aspiration on the ward screen. Services requested: PT (gait, stairs), OT (ADL, bathroom equipment), PSW 1 hour daily × 2 weeks for dressing/bath then reassess. No nursing wound. No IV. Safety: no weapons, small dog (will be crated), spouse present mornings. Patient can be left afternoons. MRP: this FP. Urgency: within 48 h of discharge, already home. Not an LTC placement referral.
Why the first visit does not happen
- Wrong address or a number that goes to a full mailbox.
- No service named, only 'needs home care.'
- Two-person transfer not stated, so a single PSW arrives and leaves.
- No MRP for the wound that needs an order tomorrow.
- Using this form as a long-term care application.
Draft the home care referral from the visit
In Scribeberry, open Forms, search for home and community care referral, or upload the current HCCSS PDF. Generate from the encounter and your notes, then edit every field before you sign. Scribeberry does not pre-map this form. You still review and sign.
Frequently asked questions
Is this the same as a long-term care application?
No. Home care is services in the current home. LTC placement is a separate medical and functional package. You can need both. Complete both.
Can I refer for PSW only?
Yes, if that is what is required. Name the ADLs. 'PSW for support' without a task is a delay.
What if the patient is not in Ontario?
Home care is provincial. Use that province's home-care or extra-mural referral. This page is the Ontario HCCSS-style referral.
Does Scribeberry send the referral to HCCSS?
No. Scribeberry helps you complete the PDF. You submit through the regional channel and keep a copy in the chart.
Forms
