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
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[ ]
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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