To optimize our central intake and referral process please include ALL required information outlined in the checklist:

Transcription

1 CPM Patient Referral Checklist To optimize our central intake and referral process please include ALL required information outlined in the checklist: Fully completed CPM Central Intake Patient Referral Form Request for Telephone Consultation (if applicable) Diagnostic Imaging - MRI and CT Reports of the affected areas no older than 5 years Medical history and list of medications Relevant consultation, treatments and surgical notes History of drug/alcohol abuse or addiction Patient demographics MD demographic and billing number (see note below) Other: IMPORTAT: Did you know that some of our Centres for Pain Management MD s have their Focused Based Practice Designation? This means referring physicians who belong to a FHT, FHO, FH and FHG practice model WILL OT be negated. Please contact our Central Intake staff if you have any questions or concerns. CPM Centres for Pain Management Central Intake Department Head Office: Millcreek Drive, Mississauga, O, L5 3E7 P: TF: Ext 1022 F: TFF:

2 Dear Primary Care Practitioner, Thank you for referring your patient with chronic pain to one of our CPM centres for assessment and/or treatment. I would like to highlight some of the benefits our centres can offer you and your patients. Centralized Intake Process: We have a Centralized Intake Process to standardize screening of each referral. This process ensures that all required information for the consultation has been received. The efficiency of this process helps us to see your patient on a timelier basis. Timely Assessment of Sub-Acute Pain: The earlier a patient with pain is treated, the more likely a successful outcome will occur. Painful conditions treated within the first 3-6 months using a multimodal approach have the highest chance of full recovery. Patients with pain for more than 18 months can typically expect some reduction in pain and improvement in the quality of life, but it is unlikely their condition will be resolved. We therefore try to prioritize patients with sub-acute pain. Timely Access to Multidisciplinary Treatments: Our goal is to provide comprehensive, caring, chronic pain management whenever possible. Many components of multidisciplinary care are not funded by OHIP. CPM will provide the Stanford-based, 6-week, Chronic Pain Self-Management Program to all CPM patients at no charge. For patients with supplemental health coverage, we can provide other elements of comprehensive care: exercise, massage, cognitive-behavioural therapy, and nutrition counselling etc. For patients without coverage we may refer to community and online resources. ew patient referrals to CPM will be prioritized based on: a. The need for a one-time consultation vs. a period of active care b. Duration of the painful condition c. Extent of 3 rd party coverage Telephone Consultation: We offer the option of a brief telephone consultation, to better support primary care practitioners (PCPs) whose patients might have to wait to be seen at our centres. This is now a funded service in the OHIP Schedule of Benefits both for the referring and consulting physician. It is suitable for a patient with chronic pain, where there are a small number of specific questions to help the PCP continue ongoing treatment. A specific 1-page referral form can be sent at your request. You can also request telephone consultation patients currently under the care of a CPM physician. We continually strive to improve our service offerings to referring physicians and patients with pain. Please contact our central intake staff if you have any questions or concerns about referring your patients to CPM. Roman D Jovey MD Medical Director CPM Centres for Pain Management Central Intake Department Head Office: Millcreek Drive, Mississauga, O, L5 3E7 P: TF: Ext 1022 F: TFF:

3 CPM Centres for Pain Management Central Intake Referral Form Patient address if available: Referring MD Information: Patient Contact Information: For Patient Label Please circle applicable practice model: FHT FHG FH FHO Other Is patient receiving Ontario Disability Benefits? Y Is patient receiving Long-Term Disability Benefits? Y Are you this patient s family physician? Y Is this a WSIB Claim? Y Claim # MVA Claim? Y Patient Medical Profile - Please indicate the clinic you wish your patient to be seen in: Medication advice only? Y Toronto Mississauga Brampton Scarborough Oakville Oshawa London Ottawa Hamilton Specific CPM MD: Request for 10 min MD phone conversation? Y If yes, please complete attached Request for Telephone Consultation form Primary Diagnosis: Length of pain complaint: History of alcohol and drug addiction? Y Patient s Past Medical Treatment Profile - Please attach a full list of current medications Has the patient received any of the treatments listed below? Secondary Diagnosis: erve Blocks SAIDs/COXIBs Opioids Psychological Counselling Cannabinoids Tricyclic Other Anti-Depressants Carbamazepine Gabapentin Pregabalin Topiramate Surgery (What/When): Interdisciplinary Pain Program (When/Where) Please attach copies of current MRI and CT reports of the affected areas as well as copies of relevant consultations, treatments and surgical notes Patient Alternative Treatment Profile Has the patient received any of the treatments for pain listed below? Physiotherapy Chiropractic Treatment TES Acupuncture aturopathic Massage Therapy I recognize that my patient is being referred into an interdisciplinary program, and when indicated will receive care from allied healthcare professionals in addition to care from a physician with pain expertise. I acknowledge that I have read the conditions of this referral and I agree to resume care for this patient after discharge. Physician Signature: Date: P: TF: Ext 1022 F: TFF:

4 Physician to Physician Telephone Consultation Physician to physician telephone consultation is a service where the referring physician, in light of his/her professional knowledge of the patient, requests the opinion of another physician (the consultant physician ) by telephone who is competent to give advice in the particular field because of the complexity, seriousness, or obscurity of the case. This service is only eligible for payment if the consultant physician has provided an opinion and/or recommendations for patient treatment and/or management. For the purpose of this service, relevant data include family/patient history, history of the presenting complaint, laboratory and diagnostic tests, where indicated and feasible in the circumstances. Definition/Required elements of service Referring physician The referring physician initiates the telephone consultation with the intention of continuing the care, treatment and management of the patient. In addition to the Constituent and Common Elements of Insured Services described in the General Preamble of this Schedule, this service includes the transmission of relevant data to the consultant physician and all other services rendered by the referring physician to obtain the advice of the consultant physician. ote: This service is eligible for payment in addition to visits or other services provided to the same patient on the same day by the same referring physician. Definition/Required elements of service Consultant physician This service includes all services rendered by the consultant physician to provide opinion/advice/recommendations on patient care, treatment and management to the referring physician. The consultant physician is required to review all relevant data provided by the referring physician. K730 Physician to physician telephone consultation Referring physician K731 Physician to physician telephone consultation Consultant physician Payment rules: 1. A maximum of one K730 service is eligible for payment per patient per day. 2. This service is only eligible for payment for a physician to physician telephone consultation service: a. that includes a minimum of 10 minutes of patient-related discussion for any given patient, and; b. where the referring physician and consultant physician are physically present in Ontario at the time of the service. Medical record requirements: Physician to physician telephone consultation is only eligible for payment where the following elements are included in the medical record for a physician who submits a claim for the service: 1. Patient s name and health number; 2. Start and stop times of the discussion; 3. ame of the referring and consultant physicians; 4. Reason for the consultation, and; 5. The opinion and recommendations of the consultant physician. Claims submission instructions: K731 is only eligible for payment if the consultant physician includes the referring physician s billing number with the claim.

5 Request for Telephone Consultation Pain Management Physician ame: OHIP Billing o. Back Line Telephone o. Best time on Tuesday to call: Patient ame: DOB: HC: Brief history of the pain problem and current treatments (attach additional pages if required): Specific questions to discuss: Date of discussion: Start Stop times: Record of issues discussed / advice given: Billing: - Referring MD: K730 Consulting MD: K731 Diagnostic Code:

6 We have Rehabilitation Services! The AIM Health Group division of Viable Healthworks offers complementary and alternative medicine and rehabilitation services at most Centres for Pain Management locations including: Acupuncture Custom Bracing and Supports Chiropractic Care Kinesiology Massage Therapy aturopathic Medicine Orthotics and Orthopaedic Shoes Personal Training Physiotherapy Corporate and Executive Medicals Ergonomic Assessments Fitness Programs In-home Assessments Lifestyle and Health Assessments Lifestyle Programs Motor Vehicle Accident Rehabilitation Wellness Programs Physical Demands Analysis Pre/Post Employment Testing Return-to-work Programs Work Conditioning/Work Hardening Our multidisciplinary services and programs include: Independent Medical Evaluations Functional Abilities Evaluations Work Site Assessment Interdisciplinary Chronic Pain Assessments WSIB Return to Work Coordination Supplements Did You Know? We currently offer nutrition and lifestyle counselling programs that may help those who have obesity, weight management disorders, metabolic syndrome, type II diabetes, hypertension, PCOS, dyslipidemia, osteoarthritis, obstructive sleep apnea, GERD, and fatty liver. The programs involve customized nutrition and exercise plans depending on individual need and may be covered in part by extended health benefits. AIM Health Group Health and Wellness Centres Head Office: Millcreek Drive, Mississauga, O, L5 3E7 P: F: See page 7 of the referral form for a list of our locations or visit

7 CPM Centres for Pain Management Brampton CPM 2 Kennedy Road South, Unit #2 Brampton, O L6W 3E1 T: F: Mississauga CPM 6400 Millcreek Drive, Unit #9 Mississauga, O L5 3E7 T: F: Scarborough CPM 1200 Markham Road, Suite #425 Scarborough, O M1H 3C3 T: F: Toronto CPM 123 Edward Street, Suite #1118 Toronto, O M5G 1E2 T: F: Oshawa CPM 1290 Keith Ross Court, 2 nd Floor Oshawa, O L1H 7K4 T: F: Oakville CPM 2125 Wyecroft Road, Unit #6 Oakville, O L6L 5L7 T: F: London CPM 458 Central Avenue London, O 6B 2E5 T: F: Ottawa CPM 550 Terminal Avenue, Unit #B22 Ottawa, O K1G 0Z3 T: F: Hamilton CPM 1605 Main Street West Hamilton, O L8S 1E6 T: F: AIM Health Group Health and Wellness Centres AIM Brampton 2 Kennedy Road South, Unit #2 Brampton, O L6W 3E1 T: F: AIM Mississauga 6400 Millcreek Drive, Unit #9 Mississauga, O L5 3E7 T: F: AIM Scarborough 1200 Markham Road, Suite #425 Scarborough, O M1H 3C3 T: F: AIM Toronto 123 Edward Street, Suite #1118 Toronto, O M5G 1E2 T: F: AIM Hamilton 1605 Main Street West Hamilton, O L8S 1E6 T: F: AIM Ottawa Hampton 1419 Carling Avenue, Suite #216 Ottawa, O K1Z 7L6 T: F: AIM Ottawa Trainyards 550 Terminal Avenue, Unit #B22 Ottawa, O K1G 0Z3 T: F: AIM Ottawa Orleans 1605 Orleans Blvd, Unit #3 Ottawa, O K1C 7E2 T: F: AIM London orth 267 Fanshawe Park Road West London, O 6G 5A9 T: F: AIM London South 320 Adelaide Street South London, O 5Z 3L2 T: F: AIM London West 1051 Wonderland Road South London, O 6K 3X4 T: F: AIM London Central 458 Central Avenue London, O 6B 2E5 T: F: AIM Waterloo 153 Union Street East Waterloo, O 2J 1C4 T: F: AIM Kitchener 550 King Street East Kitchener, O 2G 2L8 T: F: