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.
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:
- Continuing Care Referral Form
- Progress Notes
- Sample Referral Checklist
Call Zone Central Intake to make a phone referral:
- 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 providers now have access to specialist advice and consult information for their patients.
Calgary Zone
Non-urgent advice is available to Calgary Zone referring providers through Alberta Netcare eReferral Advice Request and Specialist LINK.
Non-urgent questions sent to Calgary Zone Nephrology through eReferral Advice Request are answered by a Nephrologist within five calendar days, while questions asked through Specialist LINK’s tele-advice phone line are returned within one hour.
To get started or to submit an eReferral Advice Request, visit the Alberta Netcare Learning Centre for Quick Reference Guides. For questions or support, contact the eHealth Netcare Support Services team at 1-855-643-8649 or email ehealthsupport@cgi.com.
To request tele-advice, visit www.specialistlink.ca and select the chosen specialty/group or call 403-910-2551 or toll-free at 1-844-962-5465. For more information, visit www.specialistlink.ca.
Edmonton Zone
eReferral Advice Request and Consult Request are available for referring providers in the Edmonton Zone.
Non-urgent questions sent to Edmonton Zone Nephrology through eReferral Advice Request are answered by a Nephrologist within five calendar days.
eReferral Consult Requests are requests for in-person specialist appointments and are being accepted at the following sites:
- Alberta Kidney Care North (formerly Northern Alberta Renal Program (NARP))
- IMPORTANT NOTE: Alberta Kidney Care North is accepting eReferral Consult Requests for patients located in the North, Edmonton & Central AHS Zones.
- Kingsway Nephrology Associates
- South Edmonton Nephrology
- Walter C. Mackenzie Health Sciences Centre – Nephrology
For training, visit the Alberta Netcare Learning Centre and view the Quick Reference Guides for how to submit an Advice/Consult Request. For questions or support, contact the eHealth Netcare Support Services team at 1-855-643-8649 or email ehealthsupport@cgi.com.
IMPORTANT NOTE: Do not submit urgent referrals through eReferral. If your inquiry is of a more urgent nature, please call RAAPID North (for patients north of Red Deer, Alberta): 1-800-282-9911 (Canada ONLY) or 780-735-0811; RAAPID South (for patients in and south of Red Deer, Alberta): 1-800-661-1700 (Canada ONLY) or 403-944-4486. For more information about RAAPID, go to: https://www.albertahealthservices.ca/info/Page13345.aspx.
For referral guidelines for Nephrology, view the Provincial Nephrology Referral Quick Reference.
Other Zones
eReferral is available to all Alberta Netcare users. If you do not have Alberta Netcare, contact eHealth Netcare Support Services at 1-855-643-8649 or ehealthsupport@cgi.com to get access.
For other Nephrology referral locations not covered by eReferral or Specialist LINK, click here.
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
- AHS Ethics Consult Services (must be AHS staff to view)
- Covenant Health Ethics Consult Services (must be Covenant staff to view)
