Co-ordinated Care NIS
Framework for Locality CHTs – Referral Criteria
Appendix A
Framework For Locality CHTs – Referral Criteria
Community Health Teams have been developed to provide co-ordinated health care for adults living in Tower Hamlets. The teams are multi-disciplinary,
aligned to local GP practices and provide a seven-day service between the hours of 8:00am and 10:00pm.
CHTs comprise nursing, physiotherapy, occupational therapy, care co-ordinators, speech and language therapists, psychologists and support staff and they
will work together to offer a range of interventions for patients with healthcare needs who require support within their own homes.
There will be three categories of response according to the priority and needs of the referral.Priority is based on the referral criteria detailed below
Rapid Response – within 2 hours ii. Non Routine Response – within 24 hours iii. Routine Response – 1-5 days
i.
RAPID RESPONSE (2 hours)
ii.
- To keep the person at home if safe and
possible to do so (Community Response), or to
facilitate a safe discharge
RR – Community Response for recent onset / new problems
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Sudden deterioration (within last 24 hours) – loss of
ability to transfer (e.g. move from bed / chair / toilet )
Palliative care needs – urgent review due to
deterioration or change in condition
Management of urgent catheter problems e.g. catheter
blocked
New wound, ( including pressure ulcer) requires
assessment (or existing wound needing unscheduled
review)
New medication prescribed and patient unable to selfadminister (patient has no care package)
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NON ROUTINE RESPONSE (24 hrs)
iii. ROUTINE RESPONSE (1-5 days)
- To facilitate safe and timely discharge
home from hospital or prevent an
admission to hospital / long term
placement (these are non-routine / non
urgent referrals)
For longer term rehabilitation,
improvement of functional activity,
Advice, exercise and support to
encourage self-management. Initial
assessment within 5 days.
High falls risk e.g. recurrent (2 or more)
within past 5 days. Not presented to other
health services.
General palliative care assessment- for
symptom control and psychological issues
Replacement walking aid for indoor mobility
required (not known to CES)
Non routine post surgical follow up eg clip
removal / Total Hip Replacement
contraindications
Medication need according to CHT nursing
criteria
Risk of pressure ulcer
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Physical Rehabilitation, Exercise
Programmes, functional practice etc
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Long term condition management
(excluding stroke and COPD)
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Spasticity management (excluding
stroke)
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Non urgent post surgical follow up
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Indoor and outdoor mobility – no
immediate risk of admission
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Co-ordinated Care NIS
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Framework for Locality CHTs – Referral Criteria
Fall with injury requiring assessment (recurrent non
injurious falls will be seen as per 1-5 days pathway)
Client / carer at immediate risk of injury due to manual
handling
Breakdown of urgent equipment (if not covered by CES)
Breakdown of social / care package e.g. carer in hospital
etc (Note: clients not known to the CHT’s will be
managed by First Response social care team)
Acute chest infection / aspiration. Client at risk of
admission and requires assistance with secretion
clearance(must have already been seen by
GP/Consultant within 24 hours and commenced on
antibiotics)
Urgent symptom management for long term conditions
(excluding stroke and COPD) or frial complex client
Death of a client already on caseload or in transition
from hospital
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Appendix A
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Difficulty in carrying out daily tasks
Post operative wound care requiring daily
review
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Risk of falls (not within urgent and
non routine )
Administration of injections - including
Tinzaparin/Insulin
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Client / carer at risk of injury due to
manual handling
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Issues with Swallowing
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Issues with communication due to
health diagnosis
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Vocational rehabilitation – facilitation
of return to work or study following
diagnosis of neurological condition
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Cognitive rehabilitation
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Palliative re-assessment post routine
admissions
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Facilitation of discharge from hospital
e.g. attending discharge planning
meeting
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Routine physiological assessment
e.g. BP monitoring
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Psychological distress due to health
condition
RR – Rapid supported Discharge.
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Assessment for community IV antibiotics (1st dose to be
administered in a supervised environment)
Palliative care clients requesting rapid transfer to the
community (Community Health Team to contact ward
within 2 hours)
Facilitation of discharge from ED of hospital (ie nonadmitted patients) whereby patient is at high risk of
readmission (within 24 hours)
NB: ward teams are expected to complete all necessary assessments and referrals required for safe discharge before the patient comes home. They
should also provide sufficient notice to Community Health Teams and adult social care to ensure transfer to the community is seamless (as per Joint
Hospital Discharge Policy). For example, nursing equipment e.g. hospital bed/pressure relieving mattress requires 3 working days.
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