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Community Supports & Referrals

Timely referrals can make a big difference for patients. Ongoing conversations about Continuing Care services (such as Home Care) and appropriate referrals are encouraged.

Anyone can make referrals to Continuing Care. Patients and family members must give their permission for someone to make a referral on their behalf.

Step 1: Does the patient need Continuing Care Services?

Carefully consider if your patient might benefit from any Continuing Care services now. Even if a patient does not have an identified need, provide them with early and ongoing education about Continuing Care services.

For more information see: When Should I Make a Referral to Home Care / Palliative Home Care?


Step 2: Phone or Fax the following information:

Call Zone Central Intake to make a phone referral or to request a Zone-specific referral form:

  • North Zone: 1-855-371-4122
  • Edmonton Zone: 780-496-1300
  • Central Zone: 1-855-371-4122
  • Calgary Zone: 403-943-1920
  • South Zone: 1-866-388-6380


Step 3: Patient will be assigned a Case Manager

Continuing Care will help determine the appropriate level and location of care whether it is Home Care, Facility Living, or Supportive Living. Edmonton and Calgary (and a few other locations in the province) have specialized Palliative Home Care teams. In other places, integrated Home Care teams provide services across the entire spectrum of life. As well, Palliative Consult services are usually available across the province (see below).

GFR 15 - 10 | Slow Decline | Last 0-5 years of life

Even if a patient does not have an identified need at this time, provide them with early and ongoing education about Continuing Care services. Please carefully consider if your patient might benefit from any Continuing Care services now.

GFR 10 - 5 | Deteriorating | Last 0-3 years of life

If your patient’s condition is deteriorating, his/her needs might change quickly. If they don’t already have Continuing Care services (eg. Home Care) in place, it is recommended to make this referral now.

With the patient’s permission, submit the referral for homecare and recommend palliative homecare where it is available.

GFR 5 - 0 | Intensive/Near Death | Last 0-2 months of life

If your patient is in the community setting, an immediate referral to Continuing Care (eg. Home Care) is encouraged if these connections have not yet been made. Specifically request palliative Home Care where it is available.

Additional Resources

A conservatively managed kidney disease patient may benefit from a specialized palliative care consult at any time if:

  • They have had multiple acute care admissions
  • They have symptoms that are not well controlled
  • They require hospice placement (approximately within the last 4 months of life)

In some locations in Alberta, such as in Edmonton, the request for a specialized palliative care consult must come from the patient’s GP or NP. In other parts of the province, such as in Calgary and the Central Zone, consult requests can come from other healthcare professionals connected to the patient. More information specific to each zone can be found at here.

Also, although details may vary across the province, palliative consult services are generally available regardless of where the patient is located, including in long term care facilities, supportive living, acute care, rural settings, etc.

  • North Zone: 1-855-371-4122
  • Edmonton Zone: 780-496-1300
  • Central Zone: 1-855-371-4122
  • Calgary Zone: 403-944-8294
  • South Zone: 1-866-388-6380
Additional Resources

Specialized Geriatrics Services are available in Alberta. These teams perform comprehensive assessments of older adults and make recommendations for care.

An older adult may benefit from a comprehensive geriatrics assessment if they are experiencing a change in condition, including but not limited to:

  • Falls
  • Immobility
  • Incontinence
  • Confusion

The patient’s GP/NP or attending physician should be involved in making a request for a specialized geriatrics assessment. Available services may vary depending on the patient’s location in the province.

Not all end-stage kidney disease patients will attend chronic kidney disease clinics (nor do they need to). Care professionals can still access nephrology if a consult is required.

If a telephone consult with a nephrologist is required, healthcare providers can contact RAAPID via their zone-specific numbers:

  • North: 1-800-282-9911 or 780-735-0811
  • South: 1-800-661-1700 or 403-944-4486

In the future, electronic consult services with nephrology may be available via Netcare.

If your patient requires a referral to a nephrologist, contact the nephrology group in your area.

Due to the complexity of the issues surrounding end-stage kidney disease, you may find yourself facing an ethical dilemma at some point in your clinical practice. Assistance is available.

Ethics services are available across the province through Alberta Health Services and Covenant Health.

Additional Resources
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