Complex Neurological
Rehabilitation
Referral Documents
Please submit the attached documents when making a referral for complex
neurological rehabilitation:
1. Identification of patients with Complex Neurological Rehabilitation Needs
(form 1)
2. The Rehabilitation Complexity Scale – Trauma (RCS E-Trauma) (form 2)
3. Complex Neurological Rehabilitation Referral (form 3)
1
Identification of patients with Complex Neurological
Rehabilitation Needs (form 1)
The following table must be used as a guide to identify the level of need required for
patients with complex rehabilitation needs. Please circle the descriptors which apply to the
patient in question.
Domain
Medical
management
High level needs
Unstable medical/
surgical problems
Complex investigations/
intervention required
24 hour medical cover
required on-site
Medium level needs
May require specialist
medical management
May have medical
problems requiring
routine investigation/
monitoring/intervention
Currently well but
potentially unstable
Clinical
Comments
Neuropsychiatric
needs
Complex/unstable
psychiatric needs
Psychiatric condition
stable, but requires
monitoring
High risk management
Low level needs
Medically stable
Basic
investigations/
monitoring may
be required
May have a wide
range of medical
conditions
No psychiatric
condition
Low or no risk
Medium risk management
Treatment under section
of the Mental Health Act
Clinical
Comments
Nursing care
High physical
dependency and
frequent monitoring
required
Low awareness state
2 carers required for the
majority of care needs
No need for
skilled nursing
Qualified staff nurse
No tracheostomy
interventions required
e.g. monitoring, dressings,
medication
Specialist nursing care
interventions required
Clinical
Comments
Tracheostomy/
ventilatory
Unstable tracheostomy
requiring intensive
suction
Tracheostomy in situ but
stable
No tracheostomy
Oxygen saturation
2
monitoring programme
Active weaning
programme
Assisted ventilation
Clinical
Comments
Swallowing/
nutrition
Clinical
Comments
Physical
disability
Complex swallowing
evaluation (e.g. FEES)
Enteral feeding
programme
Normal
diet/stable diet
Complex nutritional
requirements requiring
intensive dietary
support/ intervention
Moderate monitoring
required for food
consistency and/or diet
content
Able to eat
independently or
with supervision
from care staff
Dietary education
required (ie healthy
eating and weight
reduction)
Standard diet/
weight monitoring
2-3 trained therapists/
trained staff at one time
to treat
Routine physical issues
Higher function
problems only
Complex postural
tone/contracture
management
Moderate physical
disability requiring some
specialist interventions
1-2 required to treat
No/low level of
physical disability
Specialist interventions
required to manage
spasticity
Clinical
Comments
Cognition
Severe cognitive
problems – intensive
support required for
carry over or orientation
Complex cognitive/
neuropsychologist
assessment required
Highly structured
environment required to
enable functioning
Moderate cognitive
problems
Higher function
problems only
Routine cognitive
assessment required by
occupational therapy
team
No cognitive
problems
Strategies may be
required to enable
functioning
3
A structured/semistructured environment
may be required to enable
functioning
Clinical
Comments
Behavioural
Highly challenging
behaviours
(physical/verbal/aggressi
on)
Interactive behavioural
management
programme required
1:1 specialling for safety
and behaviour
management
May be a danger to self
or others
Mild/moderate
behavioural problems
generally managed well
with a behaviour
management care plan
Minimal/ no
problems with
behaviour –
managed
effectively
A structured environment
may be required
Compliance with
care
Some monitoring may be
required
Mild/moderate problems
in compliance with care
A secure facility is
not required
A secure facility may be
required
Risk of wandering or
absconding
Significant problems in
compliance with care
A secure facility required
Clinical
Comments
Mood/emotion
Severe
anxiety/depression/emo
tional lability
Specialist evaluation
required
Mood
disorder/adjustment
issues under active
management with
planned programme
No significant
mood/adjustment
issues
Active management and
frequent crisis
intervention required
Clinical
Comments
Communication
Complex communication Moderate communication
problems such as
difficulties
dysphasia combined
with
Able to communicate
Higher function
problems only
No
4
cognitive/perceptual
problems
basic needs and ideas
with/without aids
communication
problems
Complex disability
management
interventions required
such as:
 evaluation of low
awareness state
 neuro-palliative
rehabilitation/
end of life care
Standard disability
management required
such as:
 set-up of care
programme
 care booklet
 carer training
None required
Complex
placement/housing/fund
ing issues requiring
extensive multi-agency
negotiation
Active discharge planning
requiring liaison with
community social worker,
district nurse,
occupational therapist to
arrange care package
No major
discharge issues,
taken care of by
family/allocated
social worker
Complex communication
aid set up/provision
required
Specialist assistive
technology required
Clinical
Comments
Complex
disability
management
Clinical
Comments
Social/discharge
planning
Safeguarding concerns
identified – high risk
Clinical
Comments
Family support
Clinical
Comments
Emotional
pressure on staff
Clinical
Comments
Vocational
Potential safeguarding
concerns – moderate to
low risk
No safeguarding
concerns
Major family distress
Routine family support
issues requiring frequent needs (met by planned
support or crisis
meetings)
intervention
No significant
family problems
Demanding situation
requiring highly
experienced staff/extra
support for staff
Somewhat challenging
situation but manageable
Minimal or no
emotional
pressure on staff
Specialist vocational
Moderate vocational
No significant
5
rehabilitation
Clinical
Comments
Medico-legal
issues
Clinical
Comments
Specialist
equipment/
facilities
Clinical
Comments
Therapy
rehabilitation needs
such as:
 multi-disciplinary
vocational
assessment
 multi-agency
support for
return to work
support such as:
 work visits or
employer liaison
 support for other
roles e.g.
homemaker/
parenting
needs for
vocational support
Complex medico-legal
issues requiring
interaction with the
legal system such as:
 complex best
interests
decisions
 court of
protection
applications
 DoLs/PoVA
applications
 Litigation issues
 Complex mental
capacity/consent
issues
Standard medico-legal
issues such as:
 Mental capacity
evaluation
 Standard
consent/best
interests decisions
 LPoA, advance
care planning
No significant
medico-legal
issues
Highly specialist
equipment/facilities
required such as:
 Bespoke assistive
technology
 Highly specialist
seating/wheelch
air needs
 Bespoke
orthotics
 Electronic
assistive
technology
 Assisted
ventilation
Moderate specialist
equipment needs such as:
 Adapted
wheelchair/seating
 Electric standing
frame
 Treadmill/harness
training
 Assisted cycling
e.g. motor-med
 Splinting/casting
No equipment
needs
Intensive coordinated
Therapy teams
Less intensive
Basic off the shelf
equipment only
Standard exercise
facilities e.g.
plinth, bike, tilt
table, parallel bars
6
type/intensity
therapy programmes
required
specialising in complex
neurological conditions
Up to 5 therapy
disciplines involved in
therapy
Moderate to intensive
therapy programmes
required
More than 25 hours
total therapy time per
week
High intensity staffing
ratios required ie 2 or
more to treat at one
time
Up to 4 disciplines
involved in therapy
20-25 hours of total
therapy time per week
therapy
Short
rehabilitation
programmes
Rehabilitation
may be required
as part of a
specific diagnostic
group (e.g. stroke)
– treatment by a
local specialist
team
Restoration of
function
Non-specialist
rehabilitation
Local services
1-3 therapy
disciplines may be
required
Clinical
Comments
Length of
rehabilitation
Clinical
Comments
Level of need
Medium to long term
rehabilitation (2-4
months, but could be up
to 6 months or more)
Medium length
Short term
rehabilitation (1-3
rehabilitation of 6months, up to a maximum 8 weeks
of 6 months)
Category A needs
Category B needs
Category C needs
Clinical
Comments
7
The Rehabilitation Complexity Scale – Trauma (RCS
E-Trauma) (form 2)
PATIENT IDENTIFICATION
Name:
Hospital No:
Date of score:…../…../…….
For each subscale, circle highest level applicable
MEDICAL NEEDS
Describes the approximate level of medical environment required for medical/surgical/trauma management
M1
Basic investigation / monitoring / treatment
(Requiring non-acute hospital care, could be delivered in a community
hospital with day time medical cover)
M2



Specialist medical / psychiatric intervention
Specialist investigations – blood
tests, imaging etc.
On-site co-ordinated specialist
opinion / intervention
Access to specialist medical
equipment for assessment
/monitoring etc.
– for diagnosis or management/procedures
(Requiring in-patient hospital care in (DGH or specialist)
M3
Potentially unstable medical /psychiatric condition
(Requiring 24 hr availability of on-site acute medical / psychiatric cover)
M4
Post-acute general medical / surgical problem
(Requiring general emergency medical / surgical intervention, but can be
managed in DGH setting)
M5
Post-acute care – with active acute trauma needs
(Requiring acute step-down coordinated trauma care)
M6
Hyper-acute trauma needs - extended range trauma care
(Requiring hyper-acute coordinated trauma care only available in MTC)
Type of medical / surgical intervention
required:





Medical
Surgical
Trauma
Psychiatric
Other……………………………









Orthopaedic / trauma
Neurology neurosurgery
Vascular
Abdominal / Cardiothoracic
Plastics/ burns
ENT / Max-fax
Urology
Rehabilitation Medicine
Other…………………………………..
8
BASIC CARE AND SUPPORT NEEDS
Describes the approximate level of intervention required for basic self-care or level of risk
(For all centres: score both care and risk and use highest score)
CARE: Standard rehab needs
RISK: Cognitive behavioural needs
C0
Largely independent in basic care
activities
R0
No risk
C1
Requires help from 1 person
R1
Low risk – standard observations only
for most basic care needs
C2
Requires help from 2 people
But requires escorting outside the unit
R2
Medium risk – above standard observations OR
managed under MHA section
R3
High risk – above standard observations
for most basic care needs
C3
Requires help from ≥3 people
for basic care needs
C4
Requires constant 1:1 supervision
AND managed under MHA section
R4
– for safety or behavioural management
Very high risk
Requires constant 1:1 supervision
SKILLED NURSING NEEDS
Describes the level of intervention required from qualified or skilled rehab nursing staff
N0
No needs for skilled nursing
Tick nursing disciplines required:
N1
Requires intervention from a qualified nurse



(e.g. for monitoring, medication, dressings etc)
N2
Requires intervention from trained rehabilitation nursing staff
and/or mental health nurses
N3
Requires specialist nursing care




General registered nursing
ITU nurse
Specialist trauma nurse (e.g.
orthopaedic, amputee etc)
Rehab-trained nurses
Mental Health (RMN)
Other…………………………..
(e.g. for tracheostomy, behavioural management etc)
N4
Requires high dependency specialist nursing
(e.g. medically unstable, very frequent monitoring/ intervention by a
qualified nurse - hourly or more often)
9
THERAPY NEEDS
Describes the approximate level of input that is required from therapy disciplines
Therapy Disciplines: State number of different therapy disciplines required to be actively involved in treatment
TD 0
0
TD 1
1 disciplines only
TD 2
2-3 disciplines
TD 3
4-5 disciplines
TD 4
≥6 disciplines
Tick therapy disciplines required:





Physio
O/T
SLT
Dietetics
Social work





Psychology
Counselling
Orthotics
Prosthetics
Rehab Engineer





Music/art therapy
Play therapy/school
DEA/Jobcentre Plus
Recreational therapy
Other :
Therapy Intensity: State overall intensity of trained therapy intervention required from team as a whole
TI 0
No therapy intervention
(or<1 hour total/week - Rehab needs met by nursing/care staff or self-exercise programme)
TI 1
Low level – less than daily (e.g. assessment / review / maintenance / supervision)
OR Group therapy only
TI 2
Moderate – daily intervention - individual sessions with one person to treat for most sessions
OR very intensive Group programme of ≥6 hours/day
TI 3
High level – Daily intervention with therapist PLUS assistant and/or additional group sessions
TI 4
Very High level – very intensive (e.g. 2 trained therapists to treat, or total 1:1 therapy >30 hrs/week)
Total
Total T score (TD + TI) :………….
EQUIPMENT NEEDS
Describes the requirements for personal equipment
E0
No needs for special equipment
Basic Special Equipment
E1
Requires basic special equipment


Wheelchair/seating
Pressure care
Highly Specialist Equipment


Environmental control
Communication aid
10
E2
Requires highly specialist equipment
(e.g. electronic assistive technology or highly customized
equipment)
E3
Requires extremely specialist equipment




Standing frame
Off-shelf orthotic
Walking aid
Other……………………





Customised seating
Customised standing aid
Customised orthotic /
brace
Assisted Ventilation
Other……………………
State equipment type:
(ie Really fancy hi-tech trauma equipment only available
in MTC!)
TOTAL SCORE
SUMMARY
Needs
Totals:
Currently gets
Medical / Surgical / Trauma /
Psychiatric treatment
M:
Medical:
/ 6
M:
 NA  D  Other..
Basic care and support
C:
Care
/ 4
C:
 NA  D  Other..
Skilled Nursing care
N:
Nursing
/ 4
N:
 NA  D  Other..
Therapy
TD:
TD:
 NA  D  Other..
scores
Reason for unmet need
(E.g. Not available (NA), declined (D),
or Other…)
(Includes risk management)
Specialist equipment
TI:
Therapy:
/ 8
TI:
 NA  D  Other..
E:
Equipmen
t
/ 3
E:
 NA  D  Other..
Summed RCS
/ 25
Gets /25
11
Complex Neurological Rehabilitation Referral (form 3)
Contact Details
Applicant Details
Name
Address/ Trust
Tel
Email
Patient Details
Name
Address
Hospital ID no.
NHS number
Date of Birth
Consultant
GP name
GP practice address
Intervention Details
Patient diagnosis
Date of injury
Consent to referral gained:
Does the patient have
capacity to consent?
If not, who has given
consent? By what authority?
Social history
Level of physical function
prior to injury (mobility,
transfers)
Rehabilitation Complexity
Scale Score
Problem list – top 5 problems
Current intervention with
disciplines involved and
level/frequency of input
Specialist equipment
required
12
Summary of progress to date
within 500 words (including
progress with outcome
measures)
UK ROC classification of
current unit
Requested intervention
(primary intervention
required within a goal
oriented rehabilitation
programme)
Ventilated patient – monitoring and weaning required □
Cognitive rehabilitation
□
Neuro-behavioural rehabilitation (1:1 nursing support) □
Post-acute active goal oriented rehabilitation
(3-6 months)
□
Other likely rehabilitation requirements (please specify):
Justification for why the
patient’s needs cannot be
met at the current provider
Level of service required
Level 1a□ Level 1b□ Level 2a□ Level 2b□ Level 3a□ Level
3b□
Future goals for specialist
rehabilitation with
timescales (specific,
measurable, achievable,
realistic, timed SMART)
Or Goal Attainment Scale
(GAS) goals
Recommendations for length
of on-going rehabilitation
Recommendations of
specialist rehabilitation unit
(>1 provider)
Other information
13