Neuro Rehabilitation Centre
Edgware Community Hospital
Burnt Oak Broadway
Edgware, Middlesex
HA8 0AD
Tel: 0203 758 2465
Fax: 0203 758 2464
Email:
REFERRAL FORM
The information requested is essential to help us to decide on the appropriateness of the Neurological Rehabilitation Centre (NRC) for your patient and how we will best meet their needs. Your assistance in completing the form is appreciated since incomplete forms will not be accepted and will result in delay.
Please tick the box to indicate the type of service you are seeking (please see information sheet on reverse for service definitions).
q Inpatient Multidisciplinary Assessment and Rehabilitation admissions (average period of 6-8 weeks).
q Inpatient Multidisciplinary Assessment and Condition Management Programme (average period of 6-8 weeks).
q Community/Outpatient Assessment and Rehabilitation or Condition Management Programme (average 4-8 weeks)
q Vocational Rehabilitation
q Long Term Conditions Register review – 3, 6 or 12 months.
In addition to the information requested in this form we require detailed medical and therapy reports outlining the clinical status of the patient including their therapeutic goals and recent progress.
If you would like to discuss the appropriateness of a potential referral, or prioritisation criteria or potential timeframe for assessment please contact:
Nadia Jeffries– Neurosciences Clinical Lead for Rehabilitation
Tel: 0207 794 0500 x 22167 or email
or
Rakhee Prema– Neurological Conditions Management Team Lead
Tel: 0207 794 0500 x 22123 or Email:
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Further information for Referrers:
Services offered: / OneInpatient MDT Assessment and Rehabilitation / Two
Inpatient MDT Assessment and
Condition management / Three
Outpatient assessment and recommendations / Four:
Community Assessment and Rehabilitation or Condition Management
Patient profile / Patients with a neurological LTC, who require intense, focused intervention, to regain aspects of functional independence. Their needs exceed what can be met through community or outpatient services. / Patients with a neurological LTC who require specialist inpatient intervention to manage their condition and any secondary complications.
To prevent acute admissions or extended length of stay. / Patients with a neurological LTC, currently in the community who require a MDT or uni disciplinary review and recommendations for ongoing management.
This can include: Fatigue management Programme, MS Exercise Circuit group, MS Nurse review. / Patients with neurological LTC, who require intense, goal-focused intervention, to regain aspects of functional independence in their own home and community or to manage their condition and any secondary complications in the community or within their own home
Time Frame / Typically 6 to 8 weeks / 6 to 8 weeks / Maximum 6 sessions / Typically 4-8 weeks
Service Provided / Pre assessment
MDT input by specialist clinicians based on assessment findings.
Individual rehabilitation programme with long and short term goals.
Discharge planning including home assessment and transfer of care sessions. / Pre assessment.
Specialist MDT assessment and intervention including:
Postural, Pressure care and spasticity/Contracture management.
Discharge Planning
Including home assessment, equipment/support services recommendation, transfer of care sessions. / Specialist MDT assessment and recommendations.
Provision of education, signposting to available resources and liaison with involved agencies.
Provision of a named contact and planned review service.
Provision of group:
- Fatigue Management Programme
- MS Exercise Circuit group
- Uni disciplinary clinics
- MS Nurse clinic / Assessment.
Uni or multi disciplinary input by specialist clinicians based on assessment findings.
Individual rehabilitation /condition management programme with client focussed goals including: Postural, Pressure care and spasticity/Contracture management .
Inpatient Service / Community/ outpatient service
We are unable to accept individuals who: / o Require the services of a Regional Neuro-rehabilitation centre.
o Require Stroke Rehabilitation (refer to FMH or local Stroke Service).
o Require tracheostomy weaning, respiratory support or nasogastric feeding.
o Have severe challenging behaviours or who are in a low arousal state.
o Are treated under section of the Mental Healthcare Act.
o Require Social Work assessment and intervention only.
o Require Social respite or continuing care placement. / o Require Stroke Rehabilitation (refer to Barnet Intermediate Care Services ).
o Have sudden onset neurological conditions without neurological investigation.
o Clients with Parkinson’s disease who will be seen by the Edgware Hospital PD Clinic.
o If the reason for referral is predominantly as a result of mental health diagnosis or learning disability.
o Require advice only on care package provision (SW)
o Require advice only on equipment provision referrals (SSOT).
o Please note we do not have carers as part of our team –all care requirements need to be arranged via Social Services.
Services offered: / Long Term Conditions Register Review
Patient profile / Patients with progressive neurological LTC, currently in the community who require a MDT review and recommendations for ongoing management or patients with a Long Term neurological condition who have clear clinical reasoning to support the need for a review by the community team. They have no or limited carer support and is unlikely to or unable to contact the service due to cognitive or communication impairments.
Time Frame / 3, 6 or 12 month
Service Provided / Provision of a named contact and planned review service. Completed by phone, uni or multi disciplinary outpatient clinic or home assessment.
Consultant neurologist review.
CNS – MS review
Community Prioritisation: / Referrals to the Community Neurological Conditions Management Team (CNCMT) will be prioritised according local policy and to clinical need. The CNCMT consists of a Consultant Neurologist, MS Specialist nurse, OT, PT, SALT, neuropsychologist, dietician and rehabilitation assistants. Please note we do not have carers as part of our team –all care requirements need to be arranged via Social Services.
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Neurological Rehabilitation Centre
Edgware Community Hospital
Edgware HA8 0AD
Tel: 0203 758 2465
Fax: 0203 758 2464
Name and contact of Professionals and services involved:Name / Telephone
Social Worker
OT
Physio
SALT
Dietician
Psychologist
District Nurse
Day Services
Mental Health Services
BILS
MS Therapy Centre
CLINICAL INFORMATION
1.1 Diagnosis (including date/onset of condition):
1.2 Medical History:
Medical Disorders: (please tick) Medical/Surgical Procedures:
Diabetes Gastrostomy tube
Heart failure Nasogastric tube
Hypertension Tracheostomy tube
Epilepsy Ventricular shunt
MRSA positive Urinary catheter
HIV positive Supapubic catheter
Known hepatitis Other procedure (state)
Other infectious or communicable disease
1.3 Previous functional Ability within the last year (Mobility, Transfers, Activities of Daily Living, Occupation):
1.5 Summary of Medical History:
1.4 Social Situation and Home Environment:
1.5 Summary of Current Impairments (Body Functions and Structure):
Physical (motor and sensory)Sensory (vision, hearing, sensation, pain)
Bladder/Bowel/Sexual Functioning
Pressure Care (Waterlow)
Physiological Functions:
Cognition and Perception:
Psychosocial (Mood, Behaviour, interaction)
Sleep, Energy and Fatigue
Communication
Swallowing
Nutrition / Nutritional Screening Tool completed (e.g. ‘MUST’)? Yes ÿ No ÿ
Nutritional Screening Tool risk category: Low ÿ Medium ÿ High ÿ
Height: Weight: BMI:
Unintentional weight loss in the last 3 to 6 months? Yes ÿ No ÿ
Under hospital or community dietitian? Yes ÿ No ÿ
1.6 Current Functional Status:
Mobility (indoor/outdoor/stairs/bed mobility):
Functional Transfers:
Personal ADL (wash, dress, toileting, feeding)
Specialist Seating needs: / Yes/ No
Wheelchair Type:
Seating Tolerance:
Splints/Casts: / Yes/No
Regime:
Carer/ Childcare commitments
Vocational situation
Community participation
1.7 Reason for Referral; include therapy goals, estimated length of stay/ intervention, anticipated
discharge destination:
1.8 Patient and family expectations of referral:
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