Details

Has the patient consented to this referral (and the sharing of all details included) or is this a Best Interests Decision to refer? *

Yes

Does the service user agree for the information on this form to be shared with health and social care staff within the team? *

Yes

Name and phone number of referrer *

Email address of referrer (this must be supplied so we can contact you about the referral) *

Referrers relationship to patient (e.g. consultant, therapist) *

Referring from e.g. Hospital (name of hospital and ward) *

Patient title and name *

Patient preferred name

NHS number *

Date of birth *

Gender *

Address inc postcode *

Patient contact details and preferred contact method (e.g. telephone, e-mail)

GP Surgery, address and postcode *

Ethnicity

Please provide relevant POTENTIAL OR ACTUAL safeguarding concerns or issues *

Are there any risks associated with visiting or providing support for this person including challenging behaviours, medication, infection control & Moving and Handling? *

Does the visit require 2 members of staff? *

Yes

Overseas visitor? *

Yes

What is the patients main spoken language? *

Is an interpreter needed?

Yes

If yes, what language?

Does this patient or their parent/carer have a communication disability? For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s? *

What might be helpful when communicating with this patient or their parent/carer?

Is patient housebound? *

Yes

Can the patient answer the door? *

Yes

If no, is there a key safe?

Yes

If yes, please provide key safe number *

Next of kin name

Next of kin relationship

Next of kin address and contact details

Key holder?

Consent to be contacted

Service questions

Is this a referral for Adult Social Care Assessment only? *

Yes

Reason for referral, please include goals and expectations e.g. to be able to make microwave meals, wash and dress independently, mobility goals) *

Previous baseline of mobility, baseline including walking and equipment *

Current medical problem including investigations, diagnosis, treatment, therapy assessments, any falls in the last 48 hrs, *

Relevant past medical history - including - allergies or long term conditions or please provide atatchments with details if applicable *

Please attach any relevant information Upload file

Can the service user be maintained safely in their own home? *

Yes

Any infection control issues? Please consider ESBL, C.diff etc *

Who else in involved/ what other referrals have been made?

Care Home Support Team Specialist Services (Cardiology, Respiratory etc) Ageing Well Social Care Assessment CHART Assistive Technology Housing Movement and Handling Home form Hospital

District Nurses Community Rehab Well-being and Community Plus Mental Health Hospice/Continuing Healthcare mediquip Accessible Homes Team AGE UK Other

Other - please specify *

Is the service user aware of their medical diagnosis?

Yes

Is the service user taking any medication? Short and Long term medication *

Yes

If yes, please attach details Upload file

Current method of dispensing (e.g. original boxes, blister pack, automated dispenser)

Are any medications injectables including anitcipatory *

Yes

If yes - please include medication, start and stop dates, dose and timings *

Does the service user have the ability to self-administer medication? If no, how did they manage their medication prior to this referral? *

Yes

Please describe level of support e.g. physical, verbal

Are there any medications that are timebound e.g. parkinsons, diabetes? *

Pain *

Pain free Uncontrolled pain

Pain controlled with analgesia

NEWS - please provide score and details of reason for score *

If the service user has any known allergies/sensitivities/intolerances inc. drug allergies, please give details (including the impact on daily living)

Personal Care - alternative upload most recent AHP consultation if available? Upload file

If you cannot provide an attachment please give details below

Toileting - e.g. does service user have a colostomy/catheter? If the patient has a catheter, please provide reason, date inserted and date that it is due to be changed

Skin integrity e.g. pressure sores, wounds, creams or pressure relieving equipment

Nutrition/hydration/Diet - e.g. meal prep, assistance with feeding, any supplements? Please include height and weight

Environment e.g. access, tenure, stairs?

Current mobility / moving and handling considerations, including mobility aid and assistance required (Including number of staff to assits mobilise and transfer, basic methods of moving and handling, transfers)

Please provide details of equipment in place or awaiting delivery

Specialist equipment (state type) eg Knee support, neck brace, collar and cuff

Breathing aids e.g. CPAP

If the service user is currently living with a Long-Term Condition, please give details (including the impact on daily living and recovery):

Are there any overnights needs? *

Is Advanced Care Planning in place, is the service user in receipt of palliative care and is the service user fast-track funded?

Is there a DNR CPR/RESPECT document in place? And where is this kept? *

Is the service user in receipt of palliative care? *

Yes

Is the service user Fast-Track funded? *

Yes

Number of support staff needed *

Call time *

AM Tea Other

Lunch Evening

If other, please provide details of times *

Details of support needed *

If you have any questions, please contact the team on [email protected]

Kirklees Independent Living Team (KILT)