Version 5 – October 2015

Integrated Community Team Referral Form

East and North Integrated Point of Access IPA recommendation Priority 1 / 2 / 3

Tel: 01438 844344 Fax: 01438 845201

Service required – Please select from relevant service below

Community Nurses/Matron / Community Physiotherapy/ Occupational Therapy
Intermediate Care Bed Bases / Virtual Ward (Home First)
Rapid Response (Home First) / Dietetics
Speech & Language / Neuro Inpatient
Self-Management Neuro / Neuro Community Team
Specialist Palliative Care (Please select from relevant service below)

North Herts Palliative Care Providers East Herts Palliative Care Providers

Garden House Hospice
Tel: 01462 679540
Fax: 01462 483251
OOH advice line 01462 679540

Garden House Hospice at Home Tel: 01462 675758

East & North Herts Community Specialist Palliative

Care Team (covering Herts, Stevenage & Royston)
Tel: 01462 427034
Fax: 01462 427031 /

Lister Hospital

Palliative Care Team

Tel: 01438 781035
Fax: 01438 284632. /

Marie Curie

Via District Nurse /

Isabel Hospice

Community Team

Tel: 01707 382500 Fax:01707 382599
OOH advice line:

IPU & Hospice at Home Tel:

Fax: 01707 326139 01707 382500

PLEASE PHONE FOR URGENT REFERRALS OR IMMEDIATE ADVICE

PLEASE COMPLETE THE RED SECTION ON ALL REFERRALS TOGETHER WITH THE RELEVANT SECTION

Patient Details
Surname :
First Name/s :
NHS number :
Hospital No:
Date of Birth : Age :
Male /Female :
Address :
Post Code :
Home Tel : Mobile Tel : / Does the patient have a learning disability? Yes / No
Does the patient have full mental capacity? Yes / No
Mental Capacity Assessment undertaken? Yes / No
Identified risks in patient’s home? Yes / No
Patient Consent to referral? Yes / No
Has resuscitation been discussed? Yes / No
How do we gain access? ______
Keysafe in situ? Yes / No
Ethnicity:
Religion:
Marital Status: Smoking Status:
Occupation:
First Language if not English:
Interpreter needed? Yes/No /
PRIMARY DIAGNOSIS:
DATE OF DIAGNOSIS:
In-Patient Date of Admission :
Proposed discharge date : / The patient is currently :
ð  At home
ð  In Nursing/Residential Care Home
ð  In hospital (provide name of hospital, ward and consultant)
ð  Other (provide details)
Next of Kin :
Relationship to patient : / Address :
Tel :
Main Carer (if different from above):
Relationship to Patient: / Address:
Tel:
GP Name :
Surgery Name :
Tel : / Other Health Services involved:
Name :
Tel :
Adult Care Services Involved: Yes / No
Name :
Tel :
Fax :
Package of Care in place? Yes/ No / Identified Key Worker: Yes / No
Name :
Profession :
Tel :

Current Medical, Past Medical and Psychiatric History – PLEASE ATTACH SUMMARY

Date / History, tests and treatment / Consultant and hospital
Current Medication:
Drug sensitivities and Allergies :
Current Level of Mobility :
Moving & Handling Assessment carried out?
Falls History :

PLEASE COMPLETE ALL RELEVANT COLOURED SECTIONS OR THIS REFERRAL WILL NOT BE ACCEPTED

Community Nursing or Matron
Intermediate Care Bed Bases / Virtual Ward
Rapid Response Team
Reason for referral :
Date of first visit required :
Catheterised? Yes / No Last date changed?
Pressure ulcer evident? Yes / No
Category :
Treatment :
Intermediate Care Bed Bases / Medically Stable
Level 2 - Sub-acute care
Requires medication review 2-3 days
Nursing intervention at least 4 hourly / Level 3 – Facility based intermediate care
Requires low level nursing input
Cannot be managed via home based support
Community Physiotherapy
Occupational Therapy / Virtual Ward
Rapid Response Team
Reason for referral :
Current level of Function :
Previous level of Function : / Goals :
Specialist Palliative Care Referral
Is patient aware of prognosis? Yes / No
Days/Weeks/Months (please circle)
What is preferred place of care?
Has Advanced Care Planning been discussed?
Yes / No
If so, is it documented? Yes / No / Has resuscitation been discussed?
Yes / No
Is DNACPR completed? Yes / No
Reason for Referral / Service requested
Pain/symptom control
Emotional/psychological support
Assessment for hospice admission
Carer support
End of life care
Advanced care planning / Home assessment
Nurse Led Clinic
Hospital assessment
Day Care
Admission (circle)
Respite/symptom control/ terminal care
Outpatients
Hospice at Home
Community Dietetic Service
Body measurement information Date taken: _ _/_ _/
Height (m):______Weight (kg):______Actual / Reported / Estimated?
Mid Upper Arm Circumference (cm):______
Reason for Referral (Not applicable for Home Enteral Feed Referrals)
Select service required: Clinic o Housebound o Ward (please state) o:
o Malnourished requiring Nutrition Support (Malnutrition Universal Screening Tool of 2 or more)
MUST Score:
BMI:______Weight loss (kg): ______in ______weeks/months (please circle)
o Food chart started? o Nutritional milky drinks/ Meritene/Complan started?
o Weight recorded weekly? o High energy, high protein fortified meals being offered?
o Pressure ulcer (state category):
o Dysphagia (difficulty swallowing) causing lack of quantity and variety of food/drink intake
Food texture: ______Fluid thickness: ______Gastrostomy Tube Fed: o
o Diabetes: Type 1 o Type 2 o Poor blood glucose control o Newly Diagnosed o
Other e.g. allergy, FODMAP, FTT, coeliac
Neurological Services
Neuro Community Team / Self-Management
Neuro Inpatient
GCS & PTA / Site of damage
Additional Diagnosis
(include medical complications subsequent to injury) / a)
b) / c)
Transfers (on ward/ at home)
How?
With assistance of.……………. People?
Equipment/ aids used …………………….
…………………………………………………
Seating Assessment
Own wheelchair Yes No
Type …………………………………………..
If not, has a wheelchair been ordered?
Yes No
Type …………………………………………..
Currently sitting in …………………………
………………………………………………….
Time spent sitting out ……………………
………………………………………………..
Cushion: Type ……………………………. / Main physical problems and goals
Impairments: ………………………………
………………………………………………..
Changes in tone, sensation? (posture or contractures)
………………………………………………..
………………………………………………..
Goals: ………………………………………
………………………………………………..
………………………………………………..
Current casting/ splinting regime (if any):
………………………………………………..
………………………………………………..
………………………………………………..
………………………………………………..
Presence of Cognitive Problems:
a) Has any assessment taken place? Yes No
- If so, what is the MOCA Score?______, - If so, what is the ACER Score?______
b) Is there evidence of forgetfulness? Yes No
c) Is the person orientated to self, place and time? Yes No
d) Has there been evidence of new learning? Yes No
e) Best estimate of length of time able to tolerate therapy? 10mins 30mins 45mins
f) Is the person aware of their difficulties? Yes No
g) Should referral to the early memory diagnosis clinic be added? Yes No
Mood:
a) Is the person showing regular signs of distress on a daily basis? Yes No
b) Do their mood swings prevent engagement in therapy or nursing care? Yes No
c) Have you tried any interventions? Yes No
- If so, what helps?
Speech & Language
Communication Problems? Yes / No: Details: ______
______
Patient/ Carer concerns regarding:
Difficulty with clarity of speech e.g. slurring? Yes / No
Difficulty understanding what has been said? Yes / No
Difficulty finding words? Yes / No
Difficulty joining in conversations Yes / No
Difficulty reading? Yes / No
Difficulty writing/ spelling? Yes / No
Does the patient use any strategies during their day:
To help remember things? Yes / No Rest/Activity periods? Yes / No
Motivational Tools? Yes / No
Current method of communication e.g. speech, pointing, alphabet chart:______
______
Please ensure patients are aware that information will be held on computer in accordance to the
Data Protection Act
Referrer’s Name / Signature
Job Title / Telephone No
Service / Date
GP aware of referral / YES / NO
Is referrer using Systmone EPR? / YES / NO / Consent to record sharing gained? / YES / NO

Name: NHS Number: