COVID-19 Hospital Transfer Form

Introduction

The COVID-19 Hospital Transfer Form is designed for family and other caregivers of adults with intellectual and developmental disabilities. In the event of a hospital admission for COVID-19, this form communicates essential information to hospital staff, including medical information, substitute decision-maker contacts and information about support needs. It promotes the accommodation of a person’s unique communication and behavioural support needs in health care. It is recommended to prepare this form in advance of a COVID-19 emergency and have it available upon a transfer to the hospital.

Download: Hospital Transfer Form Leave us your feedback Download: COVID-19 Formulaire de Transfert Hospitalier

Supporting materials
About the tool development

How to prepare for a COVID-19 hospital visit

Information on Substitute Decision Making

According to the Ontario Health Care Consent Act, a substitute decision-maker is required when someone admitted to hospital is unable or too sick to make health care decisions on their own. Speak Up Ontario provides information on how to identify a substitute decision-maker in Ontario. Look for similar information in other jurisdictions.

For information on Power of Attorney, visit the Office of the Public Guardian and Trustee at the Ministry of Ontario. This information will not apply to other jurisdictions.
Communication tools

Consider printing and attaching a communication board to the Hospital Transfer Form as COVID19 often impacts a person’s ability to speak. Various types of communication tools for patients with COVID-19 are freely available at the Patient Provider Forum. Carefully consider the needs and abilities of the person you are choosing the tool for (e.g., ability to express choices consistently, literacy, familiarity with using communication tools, complexity and number of options on the board).For people who are unable to actively rate pain or answer yes-no questions, consider attaching a tool like Chronic Pain Scale for Nonverbal Adults with Intellectual Disabilities (CPS-NAID), available from the Centre for Pediatric Pain Research, Dalhousie University, Nova Scotia, Canada.

A COVID-19 Communication Rights Toolkit is available from Communication Disabilities Access Canada (CDAC).
Social stories

Prepare the COVID-19 Hospital Transfer Form in advance of someone falling ill with coronavirus. You can use supporting materials like social stories or pictures to discuss hospital care together. For example, Jack Plans Ahead for Coronavirus: A guide for family and carers, by Beyond Words (UK), is an illustrated resource aimed at family and carers on end of life care planning in the context of coronavirus, including hospital care.

Social story: Going to Hospital with COVID-19, by Surrey Place, May 2020

This tool is developed in response to the COVID-19 Pandemic by the Developmental Disabilities Primary Care Program of Surrey Place, Toronto, 2020. The content of this tool was subject to review by Surrey Place clinicians, primary care providers and other relevant stakeholders. Special acknowledgement of the invaluable contributions by Dr. Yona Lunsky, Director of the Azrieli Adult Neurodevelopmental Centre, and Senior Scientist at the Centre for Addiction and Mental Health, Toronto, and Dr. Ullanda Niel, family physician with special training in the care of adults with developmental disabilities from Queen’s University.

Supporting materials
How to prepare for a COVID-19 hospital visit
- Information on Substitute Decision Making
  
  According to the Ontario Health Care Consent Act, a substitute decision-maker is required when someone admitted to hospital is unable or too sick to make health care decisions on their own. Speak Up Ontario provides information on how to identify a substitute decision-maker in Ontario. Look for similar information in other jurisdictions.
  
  For information on Power of Attorney, visit the Office of the Public Guardian and Trustee at the Ministry of Ontario. This information will not apply to other jurisdictions.
- Communication tools
  
  Consider printing and attaching a communication board to the Hospital Transfer Form as COVID19 often impacts a person’s ability to speak. Various types of communication tools for patients with COVID-19 are freely available at the Patient Provider Forum. Carefully consider the needs and abilities of the person you are choosing the tool for (e.g., ability to express choices consistently, literacy, familiarity with using communication tools, complexity and number of options on the board).For people who are unable to actively rate pain or answer yes-no questions, consider attaching a tool like Chronic Pain Scale for Nonverbal Adults with Intellectual Disabilities (CPS-NAID), available from the Centre for Pediatric Pain Research, Dalhousie University, Nova Scotia, Canada.
  
  A COVID-19 Communication Rights Toolkit is available from Communication Disabilities Access Canada (CDAC).
- Social stories
  
  Prepare the COVID-19 Hospital Transfer Form in advance of someone falling ill with coronavirus. You can use supporting materials like social stories or pictures to discuss hospital care together. For example, Jack Plans Ahead for Coronavirus: A guide for family and carers, by Beyond Words (UK), is an illustrated resource aimed at family and carers on end of life care planning in the context of coronavirus, including hospital care.
  
  Social story: Going to Hospital with COVID-19, by Surrey Place, May 2020
About the tool development

This tool is developed in response to the COVID-19 Pandemic by the Developmental Disabilities Primary Care Program of Surrey Place, Toronto, 2020. The content of this tool was subject to review by Surrey Place clinicians, primary care providers and other relevant stakeholders. Special acknowledgement of the invaluable contributions by Dr. Yona Lunsky, Director of the Azrieli Adult Neurodevelopmental Centre, and Senior Scientist at the Centre for Addiction and Mental Health, Toronto, and Dr. Ullanda Niel, family physician with special training in the care of adults with developmental disabilities from Queen’s University.

All rights reserved. No part of this website may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright owner, Surrey Place. Contact the Developmental Disabilities Primary Care Program at Surrey Place at ddpcp@surreyplace.ca for permission to adapt information and tools to your local practice setting.

COVID-19 Hospital Transfer Form

COVID-19 Hospital Transfer Form

Introduction

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How to prepare for a COVID-19 hospital visit

How to prepare for a COVID-19 hospital visit

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