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How to Complete the Integrated Chronic Care Service (ICCS) Referral Form: A Step-by-Step Guide

The Integrated Chronic Care Service (ICCS) at Nova Scotia Health is a specialized clinic offering support for individuals diagnosed with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (ME), Fibromyalgia, Multiple Chemical Sensitivity/Environmental Illnesses, and Post-COVID conditions. This guide will help healthcare providers accurately complete the ICCS Referral Form, ensuring a smooth and efficient referral process for their patients.

Step 1: Patient Information

Begin by filling out the patient’s demographic information:

1. Surname and First Name: Enter the patient’s legal last and first names.
2. Permanent Address: Provide the patient’s full permanent address, including the city and postal code.
3. Contact Information: Include both the patient’s cell phone and home phone numbers.
4. Date of Birth: Enter the patient’s date of birth in DD/MM/YYYY format.
5. Sex and Gender: Indicate the patient’s sex and gender as applicable.
6. Health Card Number (HCN) and Expiry Date: Provide the patient’s HCN and its expiry date.

Step 2: Referral Information

Referral Type: Select whether this is a new patient referral or a re-referral. If it is a re-referral, provide the approximate date the patient was last seen at the ICCS.

Post-COVID Referral: Indicate if the referral is related to Post-COVID conditions. If yes, note that it is recommended to focus on managing any pre-existing conditions prior to the ICCS referral.

Step 3: Referring Primary Care Provider Information

Primary Care Provider: Indicate whether you are the primary care provider. If the patient does not have a primary care provider, check the appropriate box.

Primary Care Provider Details: Provide your name, phone number, fax number, and complete address. If you are not the primary care provider, this information is crucial for communication with the clinic.

Step 4: Primary Reason for Referral

Diagnosis: Select the condition(s) for which the patient is being referred (Chronic Fatigue Syndrome/ME, Fibromyalgia, Multiple Chemical Sensitivity/Environmental Illnesses, Post-COVID).

History of Illness & Workup: Summarize the patient’s medical history related to the diagnosis and the workup that has been completed to date.

Main Concerns: Identify and list the primary concerns that the patient is experiencing. This information will guide the ICCS team in their assessment and treatment planning.

Step 5: Presenting Complaints

Check all symptoms or conditions that apply to the patient:

• Generalized pain
• Persistent fatigue and/or exertional intolerance
• Gastrointestinal upset
• Dermatitis
• Airway/respiratory irritation
• Nonrestorative sleep
• Orthostatic intolerance
• Persistent cough
• Cognitive difficulty (“brain fog”)
• Shortness of breath
• Depression/anxiety
• Muscle pain
• Weakness
• Other mental health conditions

Step 6: Other Medical Conditions

List any additional medical conditions the patient has, providing a complete picture of their health status.

Step 7: Specialties Consulted

Check the boxes corresponding to any specialists the patient has consulted, such as Neurology, Gastroenterology, Rheumatology, etc. Attach any relevant consultation reports to the referral.

Step 8: Primary Care Provider Agreement

Ongoing Care: Confirm your agreement to provide ongoing primary care and appropriate follow-up while the patient is engaged with the ICCS.

Support Post-ICCS: Acknowledge that you will support the management of the patient’s chronic health condition following their discharge from the ICCS.

Supporting Documentation: Confirm that you have included relevant labs, diagnostic imaging, and consultation reports with the referral.

Step 9: Submission

Mail or fax the completed referral form along with any supporting documentation to the ICCS:

• Mail: Integrated Chronic Care Service, 998 Parkland Dr., Suite 203, Halifax, NS, Canada, B3M 0A6
• Fax: 1-833-875-0143

Troubleshooting Tips

• Ensure Completeness: Double-check that all sections of the form are fully completed before submission to avoid delays in processing.
• Attach Documentation: Ensure all relevant medical records, including lab results and specialist reports, are attached to provide comprehensive information for the ICCS team.
• Communication: Provide accurate contact information for both the patient and the referring provider to facilitate timely communication.

FAQs

What if the patient does not have a primary care provider?

• Indicate this on the form. The ICCS will take this into account when reviewing the referral.

Can I refer a patient with untreated psychiatric issues?

• No, patients with unstable or untreated psychiatric issues are excluded from the ICCS program.

What if the patient’s referral is related to Post-COVID conditions?

• Focus on managing pre-existing conditions before referring the patient to the ICCS.

Conclusion