Timely referrals can make a big difference for patients. Ongoing conversations about Continuing Care services (such as Home Care) and appropriate referrals are encouraged.
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:
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).
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.
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.
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.
A conservatively managed kidney disease patient may benefit from a specialized palliative care consult at any time if:
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.
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:
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:
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.
The Conservative Kidney Management (CKM) pathway is a resource for patients and care providers to help in the management of chronic kidney disease with a focus on quality of life, symptom management, and living well without dialysis. www.CKMcare.com
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