Bristol Care Coordination Centre

(Coordinating end of life care)

REFERRAL FORM

Guidelines for referrers

The Bristol Care Coordination Centre service is based at Avonmouth Medical Centre.

Address: BCCC, 1st Floor, Avonmouth Medical Centre, Collins Street, Avonmouth, Bristol BS11 9JJ

Phone number: 0117 9828315

Fax number: 0117 3167690

Email address: (please see FAQ below re information governance acceptability)

Frequently Asked Questions

What does the service provide?

  • Coordination Of Care
  • Signposting to other services, as needed

Who is the service for?

  • Palliative Care Home Support organised by Bristol Care Coordination Centre is for patients considered to have a prognosis of 6 weeks or less.
  • Bristol Care Coordination Centre also coordinates the allocation of Marie Curie nights for Bristol patients with a prognosis of 3 months or less.
  • Bristol Care Coordination can make referrals onto St Peters Hospice At Home for patients with a prognosis of 2 weeks or less.

Who can make a referral?

Any clinician involved in patient care or management, with the permission of the patient or his/her representative.

How can I make a referral?

By calling or faxing us at the above telephone numbers.

Referrals are also acceptable via email if both parties agree that this is supported by the Information Governance policies (generally nhs.net addresses are acceptable).

What information is needed?

The information specified on the proforma, to include patient details, referrer details (and specified person to contact the next day, if referral is made out of hours), and details of any key worker, if known.

When is the service open for coordination referrals?

Core hours of operation are from 8am – 6pm (Monday to Friday). 8am – 4pm (Saturday/Sunday/Bank Holidays) – the service runs for 365 days a year.

What happens outside the hours?

Any calls, whether for urgent need, advice, or for coordination referrals, will be taken by existing teams (BCH Out of Hours SPA)

Please use the main number, as above, as it will be transferred automatically to the Out of Hours SPA. Referrals for coordination taken after 8pm will be followed up the next morning – please be sure to include details and availability of keyworker or relevant clinician for follow up call.

What happens following a referral?

The Care Coordinators from PCHS will work together to coordinate care as required.

Which resources/services will be allocated by the Care Coordinators?

A plan of care will be comprise care from a range of services/teams, to include:

  • Palliative Care Home Support Service (PCHS)
  • Marie Curie
  • St Peters Hospice At Home

For further detail, discussion or feedback, your call will be welcomed on 0117 9828315.

REFERRAL FORM
Date: Time: / Source: (Phone/Fax/email) / Referral taken by:
Forename:
Surname:
Preferred Name:
NHS Number
Patient Address:
Postcode:
Contact Telephone Number(s): / Home: / Mobile:
D.O.B:
Age:
Gender:
Ethnicity:
Does the patient live alone Yes ☐ No ☐
(ifNo, with whom?) Name/Relationship:
Current Location of Patient / Home ☐Hospital ☐Other☐
Hospital: / Site
Contact Details
Other: / Place
Contact Details
Referrer Details:
(Name, Designation,
Address, Tel Number)
GP GPDetails:
(Name, Practice Name,
Address, Tel Number)
Key Worker Details:
Name, Designation,
Address, Telephone Number
Involvement in Care
Religion (Please state)
Sexual Orientation / Heterosexual ☐ Gay ☐Lesbian ☐
Bisexual ☐Other ☐
TO BE COMPLETED BY CLINICIAN:
Consent for Referral / Yes ☐ No ☐ N/A ☐
Does patient have mental capacity? / Yes ☐ No ☐ N/A ☐
DNAR Order in Place / Yes ☐ No ☐ N/A ☐
Preferred Place for Care
Preferred Place of Death
Medical/Diagnostic details
Diagnosis
Any Concurrent illnesses
Prognosis (Hours, days, weeks)
Estimated By (Name/Role)
Is the patient aware of prognosis? / Yes ☐ No ☐
Are the relatives aware of prognosis? / Yes ☐ No ☐
Any Further Comments:
Syringe driver and/or injectable medication prescribed/in place?
Anticipatory Medication: Prescribed/ In place?
Any known Allergies?
If Yes please provide details
Date of Risk Assessment / Care Plans
Location of Risk Assessment / Care Plans
Keysafe Number
Parking/Access Details
Any issues please specify
Home/Environmental Risks
(Pets, Smokers, Other)
If other please provide details
Carer/Family/Significant Relationship Details
Name:
Relationship:
Contact Tel Number:
Address: (leave blank if same as patient) / Involvement in care and/or support of patient
Care Needs (please add as much detail as possible)
Mobility (in/out of bed)
Eating and Drinking
Personal care (hygiene and comfort)
Continence
Is a catheter present? / Yes ☐ No ☐(please give details)
Communication i.e. hearing aid, glasses
Day times needs / Yes ☐ No ☐ Details
Night time needs / Yes ☐ No ☐ Details
Carer respite needs
Nursing needs (specifically requiring
registered nursing involvement)
Any uncontrolled symptoms
Any other factors
Equipment in place/required to support above care needs
Any specific services/referrals required?

21June 2016 v9