Referral Criteria for BCH Strength and Balance Groups

Patient Name: / NHS Number:

Personal Details (please print)

NHS Number:
Surname: Title:
Forename(s):
Date of Birth: Sex M/F
Address:
Postcode:
Tel No: /

Referral Details (please print)

Referrer’s Name:
Designation:
Contact Address:
Tel No:
Consultant:
GP :
GP Practice:
GP telephone number:
Date of Referral:
Next of Kin: / Relationship: /  Tel:

Patient’s First Language: Communication or Cultural needs:

Risk factors, must be completed.

Lives alone Y/N Main carer of another Y/N
Recent marked deterioration in abilities Y/N Community services expressing concern Y/N

Recent hospital discharge Y/N

Completed Multi-factorial Falls Risk Assessment Tool or recent Assessment* by Specialist Falls Service must be attached

Has the patient agreed to participate in treatment: Yes/No
Please provide details of presenting problem, related medical intervention and results of diagnostic tests:
If you are a physiotherapist, please also provide a copy of any relevant assessment you have undertaken.
Please provide past medical history and current medication (a computer summary can be attached):
Rockwood Clinical Frailty Score
Mobility level and walking aids/ wheelchair / support:-
Indoors:
Outdoors:
Any issues with access / leaving the property?
If an alternative walking aid would be beneficial please indicate that domiciliary physiotherapy is also required
Referrals made to other agencies and NHS services involved: / Risks:

Send to: Community Therapy Service – Complex Elderly Team Tel: 0117 9190290

Knowle ClinicFax: 0117 9190296

Broadfield Road, Bristol, BS4 2UH

OR E-MAIL :

Date received:

/

Prioritised by:

/

Classification:

/

Diagnosis code:

Inclusion check list: [All inclusion criteria need to be met]

(1) Patient is registered with a Bristol GP

(2) History of one or more of the following:

  • More than one fall in the last 12 months
  • Difficulty with balance or walking with a potential risk of falling
  • Presented with a single fall requiring medical attention
  • A reported fear of falling and deemed to be at high risk of falling and will derive benefits from the service.

(3) Completed* & attached to referral the BCH Multi-factorial Falls Assessment (MFRA)

or Falls Specialist Service equivalent.

Primary issues are with Strength and Balanceas identified when screening walking transfers.

(4) Falls bloods completed in the last 3 months and any issues have been managed OR a request has been made to GP to complete these bloods.

[Including: Full Blood Count, Electrolytes, Liver Function Tests, Vitamin B12, Folate, Thyroid, Calcium]

(5) Medication review has been requested or undertaken by doctor or pharmacists if patient on medications which may increase risk of falls:

Falls risk factors: Sedation?: Sedatives & hypnotics, antidepressants, psychoactive drugs (Benzodiazepines /anxiolytics; & cognitive enhancers), neuroleptics, anticonvulsants.

BP? Beta-blockers, diuretics, calcium channel blockers, other vasodilators & BP Rx.

Neuro signs? anti-manic/mood stabilisers - Lithium, neuroleptics, antidepressants, anti-psychotics – Risperdone. Parkinson’s regime.

(6) The patient:

  • Is motivated, willing and able to attend group exercise sessions once/week over a period of 12weeks(in group of staff to patient ratio of 2:10) as well as able to exercise at home
  • Has memory sufficient to remember exercises using a booklet as necessary
  • Has adequate oral intake or where issues are apparent has been referred to GP or dietitian
  • Is independently mobile+/- walking aid

Consider where mobility is limited to <50m distance providing information on applying for a Blue Badge:

Contact details on hiring a wheelchair from Red Cross0117 3012 606

  • Can sit to stand independently from a dining chair or equivalent
  • Can stand unsupported for 1 minute
  • Can shift weight from foot to foot in standing (with hand hold)
  • The persons fear of falling is unlikely to prevent independent exercise

------Transport:

Has own Transport arrangements ORTransport required

Exclusion Criteria check list:[If YES to any exclusion criteria – patient not suitable for this group]

Please place“X” in each box to confirm that patient does NOT have any of the following:

(1) Unmanagedor/andunexplained pain

(2) Unexplained significant weight loss(refer to MUST Score as indicated in BCH MFRA)

(3) Unexplained blackouts / drop attacks

(4) The following Cardiac symptoms have been considered and excluded:

(i) Symptoms of dizziness, loss of consciousness (syncope), palpitations or chest pain associated with their falls –

[do NOT refer to this group until they have been fully investigated & treated for this]

(ii) Uncontrolled or unstable angina

(iii) Arrhythmiainclusive of Resting Tachycardia >100bpm.

(iv) resting SBP >180 mmHg or DBP > 100 mmHg , where this has not been reviewed by a doctor

(v) Significant drop in BP during exercise

(vi) Unstable or acute heart failure

(5)Deteriorating neurological signs

(6)Recently significant deterioration in the health status (needing medical investigation) or acute systemic illness. (If the patient has symptoms suggestive of a urinary infection please send MSU and treat appropriately prior to referral).

(7) Uncontrolled vestibular(dizziness) disturbances.

(8) Severe breathlessness

Engagement and communication:

(8) Major visual and or hearing impairmentsthat would deem patient unsafe in a group setting.

(9) Unable to respond appropriately to physical signs of when exercise should be stopped.

(10) Impaired cognition / dementia with inability to understand simple instructions.

(11) Participants who endanger others in a way that contravenes safety standards.

Referrers name: / Designation:
*Where items in the MFRA or information for inclusion / exclusion criteria are outstanding:
  • Highlight this outstanding need to the GP or other appropriate source (Practice Nurse, Community Nurse, Intermediate Care, Falls Specialist Nurse, UHB/NBT Falls Assessment Unit, Community Therapy)
  • Make a recommendation for referral to the Strength Balance Group as appropriate.