provincial telehealth program manual: appendices · provincial telehealth program manual (draft) 6...

Provincial Telehealth Program Manual: Appendices

Updated July 2017

Table of Contents Appendix A .................................................................................................................................................... 5

Approved health care facilities ................................................................................................................. 5

Appendix B .................................................................................................................................................... 5

Provincial Telehealth Site Map .................................................................. Error! Bookmark not defined.

Appendix C .................................................................................................................................................... 9

Provincial Telehealth Contact List ............................................................. Error! Bookmark not defined.

Appendix D .................................................................................................................................................... 9

Sample Telehealth Services Application Form ....................................................................................... 10

Appendix E .................................................................................................................................................. 11

Certification form ................................................................................................................................... 10

Appendix F .................................................................................................................................................. 12

Telehealth iScheduler Access Application .............................................................................................. 12

Appendix G .................................................................................................................................................. 12

Request for Telehealth Appointment ..................................................................................................... 13

Appendix H .................................................................................................................................................. 14

Meeting and Group Session Request Form ............................................................................................ 14

Appendix I ................................................................................................................................................... 14

Telehealth Client Information Sheet ...................................................................................................... 15

Appendix J ................................................................................................................................................... 15

Room Signage ......................................................................................................................................... 16

Appendix K .................................................................................................................................................. 17

Registration Protocol .............................................................................................................................. 17

Appendix L .................................................................................................................................................. 18

Troubleshooting ..................................................................................................................................... 18

Appendix M ................................................................................................................................................. 19

Healthcare Provider Survey .................................................................................................................... 19

Appendix N .................................................................................................................................................. 20

Client/Family Survey .................................................................................. Error! Bookmark not defined.

Appendix O.................................................................................................................................................. 26

Provincial Telehealth Program Manual (Draft) 4

Support Staff Survey .................................................................................. Error! Bookmark not defined.

Appendix P .................................................................................................................................................. 28

Technical System Maintenance Checklist ............................................................................................... 31

Appendix Q ................................................................................................................................................. 31

Telehealth Unit Checklist ........................................................................................................................ 32

Appendix R .................................................................................................................................................. 32

Telehealth Equipment Tracking .............................................................................................................. 33

Appendix S .................................................................................................................................................. 33

Provincial Telehealth Advisory Committee Terms of Reference ............................................................ 34

Appendix T .................................................................................................................................................. 34

Telehealth Technical Group Terms of Reference ................................................................................... 37

Appendix A Approved health care facilities

Eastern Health

1. Agnes Pratt, St. John’s 2. Blue Crest Nursing Home- Grand Bank 3. Bonavista Pennisula Health Centre, Bonavista 4. Burin Pennisula Health Care Centre, Burin 5. Carbonear General Hospital, Carbonear 6. Carbonear Long Term Care Facility, Carbonear 7. Coish Place, Clarenville 8. Dr. AA Wilkinson Memorial Health Centre, Old Perlican 9. Dr. Albert O’Mahoney Manor, Clarenville 10. Dr. G.B. Cross Memorial Hospital, Clarenville 11. Dr. H. Bliss Murphy Cancer Centre, St. John’s 12. Dr. Leonard A. Miller Centre, St. John’s 13. Eastern Health Community Building, Marystown 14. Glenbrook Lodge, St. John’s 15. Golden Heights Manor, Bonavista 16. Grand Bank Health Centre, Grand Bank 17. Health Science Centre, St. John’s 18. Janeway Children’s Health and Rehabilitation Centre, St. John’s 19. Lions Manor, Placentia 20. Major’s Path Clinic, St. John’s 21. Methadone and Recovery Centre Building 532, St. John’s 22. Molecular Imaging Facility, St. John’s 23. Mount Pearl Square, Mt. Pearl 24. Placentia Health Centre, Placentia 25. Pleasant View Towers, St. John’s 26. St. Clare’s Mercy Hospital, St. John’s 27. St. Luke’s, St. John’s 28. St. Patrick’s Mercy Home, St. John’s 29. Taylor Building (Harbour Grace Regional Centre), Harbour Grace 30. The Grace Centre, Harbour Grace 31. Tuckamore Centre, Paradise 32. U.S. Memorial Health Centre, St. Lawrence 33. Veteran’s Pavillion, St. John’s 34. W.H. Newhook Community Health Centre, Whitbourne 35. Waterford Hospital, St. John’s

Western Health

1. Calder Health Center, Burgeo 2. Blomidon Place, Corner Brook 3. Corner Brook Long Term Care, Corner Brook


4. Downtown Clinic, Corner Brook 5. Hammond Building, Corner Brook 6. Humberwood Centre, Corner Brook 7. Monaghan Hall, Corner Brook 8. O’Connell Drive, Corner Brook 9. Western Memorial Regional Hospital, Corner Brook 10. Community Health, 20 Farm Road, Deer Lake 11. Francois Clinic, Francois 12. LaPoile Medical Clinic, LaPoile 13. Lourdes Medical Clinic, Lourdes 14. Bonne Bay Health Centre, Norris Point 15. Pollard’s Point Medical Clinic, Pollard’s Point 16. Dr. Charles LeGrow Health Centre, Port Aux Basques 17. MP Place (Barhaven), Port Aux Basques 18. Rufus Guinchard Health Centre, Port Saunders 19. Ramea Medical Clinic, Ramea 20. Psychiatry Clinic, Stephenville 21. Rehab Annex. Stephenville 22. Sir Thomas Roddick Hospital, Stephenville 23. Bay St. George Long Term Care, Stephenville Crossing 24. Woody Point Medical Clinic, Woody Point’ 25. Stephenville Crossing Clinic, Stephenville

Central Health

1. A.M, Guy Memorial Health Centre, Buchan’s 2. Baie Verte Pennisula Health Care Centre, Baie Verte 3. Dr. Hugh Twomey Health Care Centre, Botwood 4. Dr. Y.K. Jeon Kittiwake Health Centre, Brookfield 5. Change Islands Community Health Centre, Change Islands 6. Fogo Island Health Care Centre, Fogo Island 7. James Paton Memorial Regional Health Centre, Gander 8. Dr. C.V. Smith Memorial Health Centre, Glovertown 9. Central Regional Health Care Centre, Grand Falls 10. Queensway Building, Grand Falls 11. Hope Valley Centre, Grand Falls 12. Connaigre Pennisula Health Care Centre, Harbour Breton 13. Lewisporte Health & Community Services building, Lewisporte 14. Mose Ambrose Clinic, Mose Ambrose 15. Green Bay Health Care Centre, Springdale 16. Green Bay Health Centre, CONA Building, Springdale 17. Baie D’Espoir Medical Clinic, St. Alban’s 18. St. Alban’s Community Health Building, St. Alban’s 19. Conne River Health & Social Services building, Conne River 20. Killick Health Services, Grand Falls 21. Notre Dame Bay Memorial Health Centre, Twillingate

Labrador-Grenfell Health


1. Black Tickle Clinic, Black Tickle 2. Cartwright Clinic, Cartwright 3. Charlottetown Clinic, Charlottetown 4. Churchill Falls Health Centre, Churchill Falls 5. Strait of Belle Isle Health Centre, Flowers Cove 6. Labrador South Health Centre, Forteau 7. Labrador Health Centre, Goose Bay 8. Hopedale Clinic, Hopedale 9. Labrador West Health Centre, Labrador City 10. Makkovik Clini, Makkovik 11. Mary’s Harbour Clinic, Mary’s Harbour 12. Nain Clinic, Nain 13. Natuashish Clinic, Natuashish 14. Port Hope Simpson Clinic, Port Hope Simpson 15. Postville Clinic, Postville 16. Rigolet Clinic, Rigolet 17. White Bay Health Centre, Roddickton-Bide Arm 18. Charles S. Curtis Memorial Hospital, St. Anthony 19. St. Lewis Clinic, St. Lewis

Appendix B Provincial Telehealth Site Map


Appendix C

Appendix D


Sample Telehealth Services Application Form

Appendix E Certification form


Appendix F Telehealth iScheduler Access Application

Appendix G


Request for Telehealth Appointment


Appendix H

Appendix I


Telehealth Client Information Sheet


Appendix J Room Signage


Appendix K

Registration Protocol

UNDER DEVELOPMENT


Appendix L Troubleshooting


Appendix M Healthcare Provider Survey


Appendix N


Appendix O


Appendix P


Technical System Maintenance Checklist


Appendix Q Telehealth Unit Checklist


Appendix R Telehealth Equipment Tracking

UNDER DEVELOPMENT

Appendix S


Provincial Telehealth Advisory Committee Terms of Reference


Appendix T


Telehealth Technical Group Terms of Reference


Newfoundland and Labrador Centre for Health Information

www.nlchi.nl.ca

70 O’Leary Avenue, St. John’s, NL A1B 2C7

provincial telehealth program manual: appendices · provincial telehealth program manual (draft) 6...

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