INITIAL MEDICAL ELIGIBILITY
Check appropriate box(es) (To be completed by the referring practitioner: physician, physician assistant, or nurse practitioner)
Referral will NOT be processsed unless completed in full and results attached: ABG/Walk Test/Sleep Study/Palliative Oxygen
Assessment
Resting Hypoxemia: Client meets at least one of the following parameters AND supplemental oxygen is required at least 18 hours
per day.
Adults
Initial ABG on Room Air for HOCP entry : PaO
2
<
59 mmHg (ABG must be within four [4] days of Assessment/Referral form
submission)
Pediatrics (Children 17 years old and under)
Meet the British Thoracic Society Guidelines for oxygen therapy in children
Referral to pediatric respirologist
Exertional Oxygen
ABG on room air – One (1) result of PaO
2
>59 mmHg AND
One of:
Evidence of desaturation on room air during exertion, to SpO
2
<89% for a minimum of one (1) minute (Blinded six (6) minute walk
test administered with documented improved performance on oxygen versus room air (include distance walked increases by
25% and a minimum of 30 metres)
During the course of the Blinded six (6) minute walk test, evidence of desaturation on Room Air during exertion, to SpO
2
<80%
for a minimum of one (1) minute (i.e., test may be terminated; no need to demonstrate objective measured improvement)
Nocturnal Desaturation
Respiratory sleep study that demonstrates minimally 5% sleep time at SpO
2
<
85%
Non-invasive positive pressure ventilation (NIPPV) alone not adequate to maintain SpO
2
>85% on room air
Sleep study demonstrates titrated oxygen administration is required to maintain SpO
2
>85% during sleep.
Palliative Oxygen. Client must be registered with a regional Palliative Care Program
Assessment for home oxygen therapy completed by a Palliative Care Program professional.
MEDICAL ASSESSMENT/REFERRAL FORM -
HOME OXYGEN CONCENTRATOR PROGRAM (HOCP)
(January 2018)
TO BE RETAINED ON THE CLIENT COMMUNITY RECORD
1 of 2
RHA Name/Address
Client Name
Address / Postal Code
Town / City
Phone #
PHIN / MHSC#
Date of Birth Gender
Referring Practitioner: Phone:
Family Physician: Phone:
Client contact: Phone:
Diagnosis / Medications/ Significant Medical History (eg. Active Tuberculosis) – Attach with Referral ________________________________
Safety/Hazard Identification (e.g. smoking, bed bugs, violent behaviours):
________
______________________________________________
__
_____________________________________________________________________________________________________________________________
Preliminary oxygen education/safety reviewed with client/caregiver
_____________________________________________________________
REASSESSMENT FOR CONTINUED MEDICAL ELIGIBILITY – RESTING HYPOXEMIA AND EXERTIONAL ONLY
Reassessment must be done one to three months post initial eligibility/ treatment initiation
Check appropriate box(es) (To be verified/completed by regional designate)
Referral will NOT be processsed unless completed in full and results attached: ABG/Walk Test
Resting Hypoxemia: Client meets at least one of the following parameters AND supplemental oxygen is required at least
18 hours per day.
Adults
ABG on Room Air - no closer than one (1) month and not greater than three (3) months from date of Initial HOCP Entry ABG:
PaO
2
<
59 mmHg
Pediatric (Children 17 years of age and under)
Yearly testing that meet the British Thoracic Society Guidelines for oxygen therapy in children
Exertional Oxygen
ABG on room air – One (1) result of PaO
2
>59 mmHg AND
One of:
Evidence of desaturation on room air during exertion to SpO
2
<89% for a minimum of one (1) minute (Blinded six (6) minute walk
test administered with documented improved performance on oxygen versus room air (include distance walked increases by 25%
and a minimum of 30 metres)
During the course of the Blinded six (6) minute walk test, evidence of desaturation on Room Air during exertion, to SpO
2
<80% for
a minimum of one (1) minute (i.e., test may be terminated; no need to demonstrate objective measured improvement)
Regional Home Oxygen _______________________________________________ Date ________________________________
Administrator or designate Print name / signature (dd/mm/yyyy)
Disposition of Referral – Continued Medical Eligibility for HOCP
NOTE: Palliative Oxygen and Nocturnal Oxygen are exempt from reassessment for continued medical eligibility
Approved Not Approved
Reason _________________________________________________________________________________
Approved Regional Respiratory Authorizer, ______________________________________________ Date _____________________________
or Designated Provincial Respiratory Print name / signature (dd/mm/yyyy)
Consultant
(January 2018)
TO BE RETAINED ON THE CLIENT COMMUNITY RECORD
Disposition of Referral – Initial Medical Eligibility for HOCP
Approved
Not Approved Reason _____________________________________________________________________________
Approved Regional Respiratory Authorizer, ____________________________________________ Date ________________________
Regional Home Oxygen Administrator, Print name / signature (dd/mm/yyyy)
Palliative Care Program Professional or
Designated Provincial Respiratory Consultant
2 of 2
Client name: PHIN:
Oxygen Prescription / Delivery Mode
Continuous__________litres/min Exertion __________litres/min Nocturnal __________litres/min
Via:
Nasal
Other (describe):
________________________________________________________________________
Prongs
Referring physician, physician assistant or ____________________________________________ Date ________________________
nurse practitioner Print name / signature (dd/mm/yyyy)
Date of follow-up testing: