Telecare Programme Referral to WELbeing

Once completed,send by secure email (gcsx or nhs.net)

The use of fax is not recommended: if this is wholly unavoidable, please print off this form and fax a completed form to WELbeing on 01323 639755 and thenphone 01323 636388 to confirm its arrival.

Referral: Prevention/intervention (3day) Urgent/crisis need (24hrs)

Referrer details
Name & designation of person completing form
Team
What organisation do you work for? (WSCC, NHS, CSWS, GP)
Where based
E-mail address
cc e-mail address if required
Direct phone number
Date form completed / emailed or faxed to WELbeing
Customer details
NHS Number
Frameworki Number
Gender (Male/Female)
Title
Surname
First name
Name like to be called
Date of Birth
Delivery address
Postcode
Tenure (private/social/rented) / Is permission required to install equipment such as a key safe?
Telephone (landline) / Is there an electric socket within 2metres of phone point?
Mobile
Spoken language / Interpreter required?
Diagnosis of dementia Yes/No / Confirm agreement to pass details to Alzheimer’s Society
Eligible for County Council Care Support funding Yes/No / Consider Attendance Allowance etc
Customer GP details
Name
Surgery
Telephone
Information required to aid installation
Hospital discharge date (if relevant):
Are there any preferred times and / or days when the installation could not take place? Yes/No
Comments
Is the customer able to take action if they are informed of a fire, flood, gas leak etc? Yes/No
Comments
Confirm agreement for a fire safety visit? Yes/No
Is the customer likely to leave their home (wander) and potentially get lost/become confused? Yes/No
Comments
Other provider system installed? Yes/No
If yes please give details of Provider and equipment installed. Equipment should not be removed/replaced without prior agreement with other provider and customer unless there are extenuating circumstances.
Any further information: (eg dog at premises)
Contact details for access to property for installation
Name
Telephone
Relationship
Carer / family member details
Name
Telephone
Relationship
Is the above named the main unpaid carer?
Confirm agreement to pass details to CSWS / Yes / No
Does carer/family member need to be present at installation? / Yes / No
Is the telecare equipment to support an unpaid carer? / Yes / No
Has carer’s assessment been completed?
If yes provide carer number
If no confirm agreement for carer’s assessment / Yes / No
No known carer/relative (please tick box)
Primary Support Reason for Telecare - choose one only (Care Act requirement)
Physical Support: Access and Mobility Only
Sensory Support: Visual Impairment
Sensory Support: Hearing Impairment
Sensory Support: Dual Impairment
Support with Memory and Cognition
Learning Disability Support
Mental Health Support
Social Support: Support for Social Isolation / Other
Telecare Objectives
Rank in order of importance 1 to 3 (1 most important)
To reduce risks associated with falls
To provide appropriate equipment to remain independent and at home safely
To support mental health needs
To alleviate medication risks
To reduce social isolation
To support a specific health condition
To provide carersupport – reduced anxiety/improved wellbeing
Other – please explain
Intended Outcomes – this must be completed for every referral
Rank in order of importance 1 to 3 if more than one outcome
To facilitate timely hospital discharge / No of days =
To avoid future hospital admissions
To reduce domiciliary care package / No of hrs per week =
To prevent admission into care home
Customer assessment
Please give full explanation of the customer’s condition that telecare equipment will support to enable the provider to assess the most appropriate equipment to meet the specific needs/outcomes of the customer:
Other health or social care services provided to customer
Details of other health or social care services provided to customer (if known).

Author: Sue Tivey, West Sussex County Council. Published: October 2015Page 1