REFERRAL FORM / Surname:..UR No:.
Given Names:.
D.O.B:..// Sex:.
Admission Date:..Consultant:.. Ward/Clinic:... USE LABEL IF AVAILABLE
Use for requests from outside Bendigo Health only.
ALL Telephone Enquiries: 5454 7059
[the BH Referral Centre] / Current location:
Discharge Destination Address: [if different from above]
Usual GP:
REFERRAL SOURCE: (It is essential this section is fully completed).. Date: : //
Name (print): Position
Health Service: Contact No: Fax No:
Signature: ...... If inpatient, estimated ready by: //
Is this referral: URGENT ROUTINE / Is the Client aware of this referral: YES / NO
Request for INPATIENT Care: Fax to BH Referral Centre Fax No: 5454 7099
Rehabilitation Psychogeriatric Geriatric Evaluation & Management Hospice*
*Hospice direct Fax No: 5454 8357
OUTPATIENT & COMMUNITY SERVICES: (see list over) Fax to BH Referral Centre
Service[s] requested: / Fax No: 5454 7099
CLINICAL INFORMATION: Brief history of Incident / Illness and Problem(s) which need to be addressed
ЖЖ N.B.: to avoid delays, referrals of inpatients from outside Loddon-Mallee region MUST have a copy of opinion of the local rehabilitation physician or geriatrician and Medication Chart or list of medications attached and assessment from allied health, if available. ЖЖ
Investigations pending? / Key data:
DVA?
ATSI?
Weight kg
VRE? Y / N
MRSA? Y / N
Antibiotics i/v?
Frequency ……….
WB status ………..
Until / /
Attached a copy of medications
Pre-morbid Function - usual level - 4 weeks prior to recent problem(s) Insert:[Independent] [Assist] or [Dependent]
Personal Hygiene / ADL [] / Mobility [] / Transfers [] / Cognition []
Current Function on the day of referral:
Personal Hygiene / ADL [] / Mobility [] / Transfers [] / Cognition []
Prior Service Use at Home: Case Manager? ......
Home help / Hygiene assistance / Delivered meals / Nursing
Document1 Jan2010
Bendigo Health - Division of Community and Continuing Care
General Telephone Enquiries: 035454 7059 and Fax No: 035454 7099
INPATIENT SERVICES: Patients must be medically stable for Rehabilitation.– Rehabilitation: General, Orthopaedic, Neurological/CVA, Acquired Brain Injury, Spinal & Amputee.
– Geriatric Evaluation & Management (incl. reconditioning) and Psychogeriatric Assessment.
– Hospice - symptom control, respite and end of life care for people with terminal illness.
NB: If the request is for Residential Aged Care Care assessment – insert ‘HART-ACAS’ in request box.
OUTPATIENT SERVICES:
Aged Persons Mental Health Services:
Specialist mental health assessment and treatment services to people aged 65 years and over who live in the Loddon/Southern Mallee region.
Aids & Equipment Program (A&EP):
Provides people, who have permanent or long-term disabilities, with aids, equipment and home modifications.
Carer Support Services:
Support for voluntary carers of people who are frail aged or who have a disability or chronic illness. Provide support, information, advocacy and assistance to access respite services.
Community Care Options:
Case Management services for people with complex needs in the Loddon Mallee region.
Community Palliative Care:
Community based palliative care including specialist nurses services, support, bereavement services, provision of equipment, and a 24 hour on-call facility for people with a terminal illness.
Continence Service:
Assistance to people with urinary and/or anorectal dysfunction or incontinence. Home visits also provided.
Community Dental Program:
Dental services for Health Care Card, Pension Card holders and their dependants.
Diabetes Education:
Provides information, education and support in diabetes management to people in the community who have, or are at risk of having, diabetes.
Home Assessment Rehabilitation Team [HART]
– Aged Care Assessment Service: Comprehensive assessment including eligibility for Community Aged Care Packages, Respite and Residential Aged Care and Transition Care Services.
– Allied Health (Greater Bendigo): Home based assessment, rehabilitation and health monitoring for frail aged and disabled persons.
– Home and Community Care/HTH: Co-ordinates with the City of Greater Bendigo Council to access home care services eg: Meals on Wheels, Home Maintenance, General & Specific Home Care, Social Support, Transport, In-home Respite, Personal Care, and Personal Activity Groups (formerly ADASS).
Home Nursing and Support Service: [HNSS]
– District Nursing Services – Wound management, nursing support and maintenance to people with high care needs.
– Post Acute Care Services – Short term home based support for people with complex needs, after acute hospital discharge.
– Hospital in the Home – Acute hospital care provided in the home setting in selected illnesses.
Loddon Mallee Deaflink:
Information and support service for people in the Loddon Mallee region who are deaf or hearing impaired.
Outpatient Rehabilitation – JLRU/SCCRC:
Multidisciplinary rehabilitation is provided at two sites – John Lindell Rehabilitation Unit (Mercy St) and Stewart Cowen Community Rehabilitation Centre (Eaglehawk). Care is provided through a Clinic structure (General CRC and Specialist Clinics). For more information about these, see individual brochures.
• Amputee / • Complex Care (multi-trauma) / • Paediatric Rehabilitation
• Back Rehabilitation / • Diabetic Foot / • Pulmonary / CHF Rehabilitation
• Brain Trauma Rehabilitation / • Falls & Balance disorders / • Progressive Neurological Disorder
(includes ABI Community Living Program) / • General Community Rehabilitation / • Rheumatology Rehabilitation
• CDAMS (memory) / • Hand & Upper Limb Rehabilitation / • Spinal Cord Injury
• Chronic Illness / • Pain Clinic – Senior Stream / • Wounds / Lymphoedema
• Pain Clinic – Younger Persons Stream / • Work Rehabilitation
Several of these clinics have mandatory pre-assessment tests or documentation – expect requests with appointment.
Rehabilitation in the Home
A program providing multidisciplinary care to people in their own homes, allowing them to leave hospital sooner.
Residential in-Reach:
Short term care and support to enable RACF residents to avoid hospital admission.
Rural Health Team:
Subregional program to provide allied health services to frail aged and disabled people living in rural communities.
Veteran Affairs Network:
Information and assistance to Veterans and their families, ex-service organisations and other service providers.
Document1 Jan2010