Therapy at Home Team Homerton University Hospital NHS Foundation Trust Homerton Row London E9 6SR Tel: 0208 510 7750 Fax: 0208 510 5049 Therapy at Home Team REFERRAL FORM & Screening checklist Criteria Checklist (Please Tick Boxes): Resident of City & Hackney Over 18 years Motivated to participate in active rehab or requires resettlement [] [ ] [ ] Has potential to return to or remain in the community with short term intensive intervention [ ] Ie input will facilitate discharge or avoid admission to hospital or long term care Has specific functional therapeutic or resettlement goals and potential to improve within 6 weeks [ ] Has had a Stroke or non progressive neurological or physical condition [ ] Please see page 3 for full details Surname: Neuro/ Generic Rehab/ Resettlement Forename: Referral Source: (Name / Dept. / Contact No) D.O.B: Gender: Goals for TAHT (expected to be met within 6 weeks): Address Postcode: Phone No: Ethnicity: At Home: Discharge Date and Ward: /Estimated discharge date: First Language: Interpreter required? Lives with: Next of Kin: Name: Address: Type of accommodation: GP details: Name: Address: Relationship: Postcode: Postcode: Telephone No: Telephone: Relevant Medical History: Current Diagnosis: Past Medical History: Therapy At Home Team Referrals 0208 5107750 8.30-10am daily. Fax 0208 5105049 M/F Surname: Forename: D.O.B: Key: A2 = Requires assistance of 2 SV = Requires supervision N = Not Assessed A1 = Requires assistance of 1 I = Independent D= Fully Dependent PRETASK CURRENT PREDICTED COMMENTS ADMISSION Bed Mobility Transfers Mobility indoors Mobility outdoors Stairs Eating/drinking Meal preparation/ household tasks Self-care Communication / Thinking Swallowing /maintaining nutrition Any specific orthopaedic protocol or follow up appointments?: Current weight bearing status (inc. time-frame if known): Equipment & care package information: Able to self medicate? If not then how? Any other services involved? (inc. contact details) RISKS:Are there any reasons why this client should not be visited alone? (e.g. History of verbal abuse, substance abuse, mental health problems, falls, Manual Handling issues?) Any other information that may be helpful to us? e.g. access issues, scores of recent MMSE /AMT or other cognitive assessments, or outcome measures you may have completed e.g. TUAG/360 turn. PLEASE INCLUDE BARTHEL SCORE IF KNOWN: If the patient has had falls, please provide details, i.e. first fall, have they been seen on the Bryning falls unit, any known reasons for falls? Therapy At Home Team Referrals 0208 5107750 8.30-10am daily. Fax 02085105049 Surname: Forename: D.O.B: Therapy at Home (neurological and generic) Teams Information Remit: To provide; o Up to 6 weeks of intensive functional rehabilitation in clients own home (for non progressive neurological and generic conditions) o 2-3 weeks resettlement in clients own home with goals for intervention rather than rehabilitation to reduce risks and maximise function. in order to: Facilitate early and timely discharge from hospital (including Early Supported Stroke Discharge) Prevent unnecessary hospital admissions Promote faster recovery from illness Reduce number of clients unnecessarily entering long term residential care Maximise clients potential for independent living including support to access universal community services. REFERRAL CRITERIA FOR THERAPY AT HOME TEAM (T@HT): 1. Resident of City & Hackney The person being referred must be a City and Hackney resident in order for them to be eligible for T@HT service provision i.e. they need to: Have lived at a City & Hackney address for at least 6 weeks prior to admission Pay council tax to the City of London or Hackney Borough Council 2. Over 18 years 3. Client / carers are willing to work with the Therapists / Therapy Assistants in setting and working towards realistic goals by engaging in a programme of active rehabilitation / intervention I.e. clients / carers are motivated to participate in active rehab / resettlement intervention addressing goals they wish to achieve. Referrals should state goals that clients / carers wish to work on with our therapists and assistants. 4. Have potential to return to or remain in the community with short term intensive functional intervention I.e. input will facilitate hospital discharge or exit from nursing / residential care into the community or prevent unnecessary hospital admission or clients entering long term care by maximising independent living for those whose abilities have deteriorated 5. To have specific functional therapeutic or resettlement goals and potential to improve within 6 weeks I.e. Resettlement will be for a short period (usually 2 -3 weeks – not a single visit) of intervention to aid the transition from hospital to home focusing on managing risk and enabling maintenance / maximum function at home rather than rehab goals. Client may not have any rehabilitation potential but carers and family etc may need advice re. using a hoist, positioning and swallowing strategies. Ward therapists must have discussed issues with the family / carers before discharge. 6. To require input from at least one of the therapeutic disciplines and a Therapy Assistant Exclusions: Under 18 years Reside outside of the London Boroughs of City and Hackney or have resided there for less than 6 weeks Where the person’s needs are primarily nursing or medical issues Where ongoing acute medical illness, precludes participation in an active rehabilitation programme Where person’s needs are likely to require more than 6 weeks intervention or require management of progressive long term conditions (refer to ACRT) Where the client refuses intervention by the Therapy At Home Team Where resettlement issues result from inadequate discharge planning Where the person’s care needs would be better met from access to the First Response Provider Team, Access team, mainstream care services or other community therapy services. Where clients reside within nursing / residential homes and goals are not anticipated to enable them to move into the community Please note: If you are unsure whether the person you are considering meets the referral criteria above please do not hesitate to contact the therapy team during referral screening Mon to Fri 8.30-10am on 020 8510 7750 to discuss and for advice on other teams if not appropriate – we try to be as flexible as possible. Therapy At Home Team Referrals 0208 5107750 8.30-10am daily. Fax 02085105049