What the 4768-69 is for
The Fixing Long-Term Care Act, 2021 requires a health assessment when a person applies to have their eligibility for long-term care determined. It covers the person’s physical and mental health and their needs for medical treatment and care. Ontario Health atHome, as placement co-ordinator, uses it to decide eligibility, then sends it to the homes the applicant chose.
Referrals for home care services go to Ontario Health atHome on a separate referral form.
Who completes it
A physician, a nurse practitioner, or a registered nurse completes and signs the assessment. The placement co-ordinator fills in their contact details and the return fax number at the top. The applicant completes nothing on the form.
How to fill in the assessment
Status of Assessment
Tick initial assessment if this is the first time you have completed the form for this applicant, and complete every section. Tick reassessment if you completed one before, give the earlier date if known, and say whether their health has changed. Under the guide, an unchanged reassessment needs only the applicant and practitioner sections and your signature.
Medical Diagnoses and Advance Care Planning
Focus on current diagnoses that bear on care in long-term care. You can attach the cumulative patient profile and tick the box instead of listing them. Record any advance care or end-of-life planning you know of, and who you discussed it with.
Current Medications
List all medications, including non-prescription ones and supplements where known. The form asks you to flag priority medications: benzodiazepines, antipsychotics, other psychotropics, opioids, and diuretics or antiglycemics, with their purpose. Record oxygen use and any drug stopped in the past three months.
Substance use, behaviours and wounds
Say whether there is a substance use disorder or dependence, and give the prescriber and pharmacy for opioid agonist treatment. Describe responsive behaviours from the last 12 months with frequency, triggers and what works. For wounds, give the type, whether a VAC is used, and the wound care specialist.
TB, ARO screening and devices
Complete the TB symptom screen. A chest X-ray is needed only if symptoms are new or worsening, and then you attach the result. Do the risk factor screen where possible, note any ARO screening in the past six months, and tick devices such as CPAP, insulin pumps or power wheelchairs.
Practitioner Information
Say whether you are the applicant’s primary care provider, and whether the primary care provider will keep caring for them after admission. Sign and date.
Common reasons it’s delayed
- An unsigned form.
- Priority medications listed without their purpose.
- Responsive behaviours left blank rather than marked none or not known.
- TB symptom screen not done, or a symptomatic applicant with no chest X-ray attached.
- Attachments not faxed with the form.
Submitting and who pays
Send the completed form and attachments to the local Ontario Health atHome office at the fax number on page one. If you fax it, fax any additional documents with it. The form has a fee code field at the top for billing its completion.