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Appendix B- NWT Long Term Care Facility Admission Application Form

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Appendix B- NWT Long Term Care Facility Admission Application Form Powered By Docstoc
					Long Term Care Assessment and Application Package Cover Sheet

All of the forms listed below must be completed and sent to the Territorial Admissions Committee for
review for an Applicant to be approved for admission to an NWT long term care facility.

List of forms:

□ Appendix B- NWT Long Term Care Facility Admission Application Form

□ Appendix C- Consent for Admission and Payment for Long Term Care

□ Appendix D- Medical Assessment Form/Client History- Confidential

□ Appendix E- Continuing Care Assessment Package (CCAP) available online:
http://www.hlthss.gov.nt.ca/english/publications/manual_results.asp?ID=75

□ Appendix F- Request for Fee Exemption (If applicable)
ATTN: Chair of Territorial Admission Committee
Primary Community Services
Department of Health and Social Services
Government of the Northwest Territories
P.O. BOX 1320 CST-7
Yellowknife, NT X1A 2L9
Phone: (867) 873-7459                                 Fax: (867) 920-3088


Health and Social Services Primary Care Providers Contact Info:

 Name:                                              Position:
 Community:                                         Region:
 Phone:                                             Fax:




As primary care provider/case manager for                                        (Client name), I
declare the attached forms have been completed in consultation with the applicant; and to the best of
my knowledge the information is complete and correct. I will be the primary contact for all
communication related to this client’s application for admission to Long Term Care and my contact
information is provided above.




Signature of Care Provider/Case Manager                Name of Care Provider/Case Manager (printed)
                                       APPENDIX A
                               Continuing care levels of service

 Levels of Service              Definition
 Level 1                        This level of service need identifies a person who is independently
                                mobile, with or without mechanical aides, requires minimal non-
 Home Care                      professional assistance with the activities of daily living including,
                                but not limited to, administration of medication, grooming,
                                bathing, eating and toileting. A person recognized as Level 1
                                wouldn’t normally be admitted to a residential care facility.

 Level 2                        This level of service need identifies a person who is independently
                                mobile with or without mechanical aides (walkers, wheelchairs
 Home Care                      etc.), requires moderate assistance with activities of daily living (as
                                above) and requires a limited amount of daily professional nursing
                                care and/ or supervision.

 Level 3                        Clients identified as requiring this level of service have heavier
                                care requirements and need additional nursing and other support
 Long Term Care                 staff time and / or supervision. Care requirements for function
                                deficits identified as needing this level of service result from
                                multiple medical diagnosis and/ or moderate cognitive impairment.

 Level 4                        Clients identified as needing this level of service remain
                                independently mobile, with multiple diagnosis resulting in
 Long Term Care                 significant physical frailty, and/ or severe cognitive impairment
                                with behavioural problems, and require considerable assistance
                                with all activities of daily living. Clients require a heavier level of
                                service and considerable more nursing and other staff time than
                                other staff time than those at Level 3.

 Level 5                  This level of service need recognizes the person with severe
                          chronic disabilities which have resulted in physical frailty and/or
                          cognitive impairment and require 24 hour a day professional
 Extended Care            nursing services and continuing medical supervision, but does not
                          require acute care services. Clients at this level are usually not
                          independently mobile, with or without, mechanical aides, and have
                          a limited potential for rehabilitation and often require institutional
                          care on a permanent basis.
Continuing Care Framework & Action Plan June, 2002




Policy for Admissions to Long Term Care Facility March 25, 2009                               Page 1 of 1
                                                                                                     NWT LoNg Term Care
                                                                                     FaCiLiTy admissioN appLiCaTioN Form
                                                                                                              appeNdix B

 Name of Applicant - Last Name                                                             First Name                                                       Middle Name


 Mailing Address                                                                                                                                   Postal Code


 Telephone Number                    Social Insurance Number Date of Birth - Y/M/D                              Gender                             Application Date - Y/M/D
 (         )                                    /             /                        /            /               Male  Female 20                           /           /
 Name/Location (Community) of Facility - 1st Choice                                          Name/Location (Community) of Facility - 2nd Choice



 Marital Status
                             Single             Married             Common-law                  Divorced              Separated               Widowed
 if married or Common-law, please complete:
 Name of Spouse - Last Name                                                                  First Name                                                    Middle Name


 Telephone Number                                                          Health Care Card Number                                                 Date of Birth - Y/M/D
 (         )                                                                                                                                                        /           /
 Type of Current residence (place normally resided):
                                                                                                Special Care Home or Level 2, 3, 4 Care in Hospital
      House (single family - detached)                                                         Personal Care Home
      Apartment (self contained, including attached housing)                                   Other Care Home (group, approved, etc.)
        - Senior Citizen’s Housing/Public Housing:  Yes  No                                   Boarding House/Rooming House/Hotel
        - Assisted Living Housing:                                   Yes  No                  Rehab Facility
 Current Living arrangements:
      Lived Alone             With Spouse Only                   With Spouse and Others                   With Other Family Member(s)                       With Others


 The following should be completed with the help of your primary care provider or home care nurse
 Current Level of Care:                 Level 1       Home Care                  Level 3       Long Term Care                   Level 5       Extended Care
                                        Level 2       Home Care                  Level 4       Long Term Care
 if applicable:
                                         Transfer from another facility                        Waiting LTC placement
 services received Within previous six months:
      Home Care                                      Night Care                                                                       Mental Health
      Hospital - Outpatient                          Adult Day Program                                                                Addiction Counselling
      Hospital - Inpatient                           Temporary Care (respite, convalescence, etc.)                                    Rehab/Therapy
      Hospital - Emergency                           Long Term Care
 main Factor Contributing to application:
      Accident or Illness of Resident                                                                   Client Needs Exceed Home Care/Facility
      Gradual Loss of Functional Abilities                                                              Respite for Supporter in Community
      Death or Serious Illness of Resident’s Spouse/Supporter                                           Lack of Social Contact
      Breakdown in Support Previously Provided by Another Supporter                                     Other, Explain:

Translation into other NWT official languages will be provided upon reasonable request. La traduction dans une autre langue officielle des T.N.-O. sera fournie sur demande raisonnable.

NWT8839/0709                                  Policy for Admissions to Long Term Care Facility March 26, 2009                                                           Page 1 of 2
 declaration


     I declare that all of the information I have provided is complete and correct. I consent to the use
     of this information by GNWT Health and Social Services for the purpose of determining my
     entitlement for other health care benefits or programs, but not for disclosure to any person or
     organization without my approval.




                                                        Name of Applicant/Responsible Party (Please Print)




                        X
                                                   Signature of Applicant/Responsible Party                                             Date - Y/M/D




                                        Name of Health and Social Services Authority Case Manager (Please Print)




                        X
                                   Signature of Health and Social Services Authority Case Manager                                       Date - Y/M/D




           For more information about how to apply for long term care please call your local
                                Health and social services authority.




  The personal information on this form is being collected under the Health Insurance and Health and Social Services Administration
  Act and will be used to assess the client’s eligibility and need in order to ensure provision of appropriate service, i.e., home care,
  long term care or respite. It is protected by the privacy provisions of the Access to Information and Protection of Privacy Act. If you
  have any questions about the collection or use, contact the Chair of the Territorial Admissions Committee at 1-867-920-6280.




Translation into other NWT official languages will be provided upon reasonable request. La traduction dans une autre langue officielle des T.N.-O. sera fournie sur demande raisonnable.

NWT8839/0709                                  Policy for Admissions to Long Term Care Facility March 26, 2009                                                           Page 2 of 2
                                                                                                     CONSENT FOR ADMISSION
                                                                                            AND PAYMENT FOR LONG TERM CARE
                                                                                                                APPENDIx C
All residents of long term care facilities must pay a fee of $712.00 per month on the first day of each month to cover the
costs of room and board. If a resident is under the age of 65 and unable to pay the full costs they may make an application
to Income Support Program for assistance. Upon admission of the resident, the Facility may require additional fees to cover
the costs of personal items.

 Name of Applicant - Last Name                                                            First Name                                                     Middle Name


 Telephone Number                                             Health Care Card Number                                      Date of Birth - Y/M/D
 (         )                                                                                                                                    /               /

                                     I agree to pay $712.00 per month on the first day of each month.

 Source of income for payment:


 Method of payment:                 Check              Cash             Direct Deposit


                                                                                               X
          Name of Applicant/Responsible Party (Please Print)                                        Signature of Applicant/Responsible Party                        Date - Y/M/D


                                                                                               X
                        Name of Witness (Please Print)                                                           Signature of Witness                               Date - Y/M/D



  This section is to be completed by the Interpreter

     I,                                                                                                                (interpreter’s name) confirm that I have

     explained the nature of this application for Admission into an NWT long term care facility, including the NWT Facility

     Application, Medical Assessment, Continuing Care Assessment and Placement, and Consent for Admission forms

     to                                                                                                              (above named applicant and/or guardian)

     in the presence of                                                                                                     (name of witness) to the best of my

     ability, and to the best of my knowledge, the applicant or guardian, fully understands the context of this agreement.


                                                                                               X
                       Name of Interpreter (Please Print)                                                       Signature of Interpreter                            Date - Y/M/D


                                                                                               X
                        Name of Witness (Please Print)                                                           Signature of Witness                               Date - Y/M/D



  The personal information on this form is being collected under the Health Insurance and Health and Social Services Administration
  Act and will be used to assess the client’s eligibility and need in order to ensure provision of appropriate service, i.e., home care,
  long term care or respite. It is protected by the privacy provisions of the Access to Information and Protection of Privacy Act. If you
  have any questions about the collection or use, contact the Chair of the Territorial Admissions Committee at 1-867-920-6280.

Translation into other NWT official languages will be provided upon reasonable request. La traduction dans une autre langue officielle des T.N.-O. sera fournie sur demande raisonnable.

NWT8840/0709                                  Policy for Admissions to Long Term Care Facility March 26, 2009                                                           Page 1 of 1
                                                                     MEDICAL ASSESSMENT FORM /CLIENT HISTORY
                                                                                                  AppENDIx D

                                                                                                                     - CONFIDENTIAL -
 To be completed by physician or Nurse practitioner
 Name of Applicant - Last Name                                                              First Name                                                     Middle Name


 Mailing Address                                                                                                                                   Postal Code


 Telephone Number                              Health Care Card Number                      Date of Birth - Y/M/D                         Date of Examination - Y/M/D
 (         )                                                                                                   /            /                                /            /
 Allergies:                                                                                 Diet:


 Active Medical Diagnosis in Order of priority:

     1.                                                                                        6.

     2.                                                                                        7.

     3.                                                                                        8.

     4.                                                                                        9.

     5.                                                                                       10.

 previous and Current History (to include relevant medical, surgical, psychiatric history, alcohol/drug dependence and
 communicable diseases):




 Current Medications:




Translation into other NWT official languages will be provided upon reasonable request. La traduction dans une autre langue officielle des T.N.-O. sera fournie sur demande raisonnable.

NWT8841/0709                                  Policy for Admissions to Long Term Care Facility March 26, 2009                                                           Page 1 of 2
                                                                                                                                        - CONFIDENTIAL -



                                 physical Exam                                                                         Laboratory Findings

   Bp                       HT                 (cm)          WT                 (kg)            CBC:


   Integument:                                                                                  Renal panel:


   CNS:                                                                                         Hepatic panel:


   Respiratory:                                                                                 Glucose:


   Cardiovascular:                                                                              U/A:


   Gastrointestinal:                                                                            MRSA/VRE:


   Genitourinary:                                                                               Hepatitis B:


   Musculoskeletal:                                                                             TB Screen:


                                                                                                Date of last CxR (Y/M/D):
                                                                                                (attach copy of results)                                  /            /

                                                                                                Immunization Status:                                          (attach record)




                                                      Name of Physician or Nurse Practitioner (Please Print)




                        X
                                                 Signature of Physician or Nurse Practitioner                                           Date - Y/M/D




  The personal information on this form is being collected under the Health Insurance and Health and Social Services Administration
  Act and will be used to assess the client’s eligibility and need in order to ensure provision of appropriate service, i.e., home care,
  long term care or respite. It is protected by the privacy provisions of the Access to Information and Protection of Privacy Act. If you
  have any questions about the collection or use, contact the Chair of the Territorial Admissions Committee at 1-867-920-6280.


Translation into other NWT official languages will be provided upon reasonable request. La traduction dans une autre langue officielle des T.N.-O. sera fournie sur demande raisonnable.

NWT8841/0709                                  Policy for Admissions to Long Term Care Facility March 26, 2009                                                           Page 2 of 2
                                                                                                            REQUEST FOR FEE EXEMPTION
                                                                                                                            APPENdIX F


Due to financial hardship, I                                                                                                                              (name of applicant)
am requesting permission for exemption from fee payment associated with the room and board for permanent placement
provided to a long term care facility in the NWT (name of facility to be determined). I understand that this requires a ‘Means
Assessment’ of my financial status by the Income Assistance Program.



  declaration

    I declare that I have read, understood and agree to having my Primary Care Provider (Case Manager) arrange with
    the Social Worker and Client Services Officer, Income Assistance for a ‘Means Assessment’ to determine my
    eligibility for exemption for fee payment.


                                                                                               X
           Name of Applicant/Responsible Party (Please Print)                                       Signature of Applicant/Responsible Party                      Date - Y/M/D


                                                                                               X
                        Name of Witness (Please Print)                                                           Signature of Witness                             Date - Y/M/D




  Office Use Only

   Administration Section



                           Approved for Exemption                                               Not Approved for Exemption



                                              Name of Client Services Officer, Income Assistance (Please Print)


                         X
                                            Signature of Client Services Officer, Income Assistance                                         Date - Y/M/D




  The personal information on this form is being collected under the Health Insurance and Health and Social Services Administration
  Act and will be used to assess the client’s eligibility and need in order to ensure provision of appropriate service, i.e., home care,
  long term care or respite. It is protected by the privacy provisions of the Access to Information and Protection of Privacy Act. If you
  have any questions about the collection or use, contact the Chair of the Territorial Admissions Committee at 1-867-920-6280.




Translation into other NWT official languages will be provided upon reasonable request. La traduction dans une autre langue officielle des T.N.-O. sera fournie sur demande raisonnable.

NWT8842/0709                                  Policy for Admissions to Long Term Care Facility March 26, 2009                                                           Page 1 of 1

				
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