ELDER CARE PROGRAM
MSJ HOSPITAL
REFERRAL FORM- INPATIENT SERVICES
3080 Prince Edward Street
Vancouver, BC, V5T 3N4
Phone: 604.877.8183
Fax: 604.877.8165
PLEASE COMPLETE ALL SECTIONS AND REVIEW THE REFERRAL CHECKLIST.
WE WILL CONTACT YOU TO DISCUSS FURTHER DETAILS REGARDING HOW WE MAY ASSIST IN CARE.
GENERAL INFORMATION
Client name:
DOB (m/d/y):
Facility (Name) / Home address:
Postal code:
Home Telephone:
Referral date:
PHN:
Referring person:
Family physician:
Aware of referral?
Yes
Phone:
Client agrees with referral?
Caregiver agrees with referral?
Yes
Yes
No
No
Fax:
Phone:
Fax:
Power of Attorney:
Substitute Decision-Maker:
Community services involved in care
(level of home supports, caregivers):
Yes
Yes
Phone:
No
Family/Significant Other:
Is client known to:
Continuing Care
Mental Health Team
Male
Female
No Contact: __________
No Contact: __________
What is the anticipated disposition?
Home alone
Home with family/caregivers
Home with home support
Assisted Living
Intermediate Care
ECU
REFERRAL CHECKLIST
Service being requested by referring person (please refer to the admission criteria for each service):
Geriatric Psychiatry Inpatient Unit
Geriatric Medicine Inpatient Unit
Please provide
previous psychiatric and medical consultations and recent assessments.
recent relevant investigations.
most recent Medication Administration Record.
most recent Medication Allergies Record.
any pertinent Mental Health Act forms.
Power of Attorney documentation.
Representation Agreement documentation.
Level of Intervention (if known).
Draft Jan. 4, 2010
Page 1 of 4
3080 Prince Edward Street
Vancouver, BC, V5T 3N4
Phone: 604.877.8183
Fax: 604.877.8165
ELDER CARE PROGRAM
MSJ HOSPITAL
REFERRAL FORM- INPATIENT SERVICES
CURRENT CARE NEEDS AND FUNCTIONAL STATUS
Communication:
Are there any barriers (language,
aphasias)?
Sleep patterns:
Sleeps all/most of the night without medication
Sleeps all/most of the night with medication
Disrupted
Precautions:
MRSA
VRE
HEP B
HEP C
TB
Bladder management:
Continent
Incontinent
Bowel management:
Continent
Incontinent
Language(s) spoken?
Safety:
Wandering risk
Determined elopement risk
Mistreatment/abuse/neglect suspected
CURRENT ACTIVITIES OF DAILY LIVING
Washing:
Indep
Supervision
1p Assist
Dependent
Reluctant
Refuses
Dressing:
Indep
Supervision
1p Assist
Dependent
Cueing
Feeding:
Indep
Supervision
1p Assist
Dependent
Difficulty swallowing
Toileting:
Indep
Supervision
1p Assist
Dependent
Med taking:
Indep
Supervision
Bubble-pack
Refuses
Cueing
Cueing
CURRENT MOBILITY STATUS
Mobility:
Indep
Supervision
1p Assist
Cognitive
impairment:
Mild
Moderate
Severe
2p Assist
Lift
Wheelchair
Please identify as specifically as possible the FUNCTIONAL GOALS OF ADMISSION:
MEDICAL STATUS/GOALS OF REFERRAL
Medical/Surgical History:
Please identify as specifically as possible the MEDICAL GOALS OF ADMISSION:
Draft Jan. 4, 2010
Page 2 of 4
Walker
ELDER CARE PROGRAM
MSJ HOSPITAL
REFERRAL FORM- INPATIENT SERVICES
3080 Prince Edward Street
Vancouver, BC, V5T 3N4
Phone: 604.877.8183
Fax: 604.877.8165
PSYCHIATRIC STATUS/GOALS OF REFERRAL
Reason for referral (check all that apply):
Mood Disorder – severe
Suicide attempt
Suicidal ideation
Psychosis
Cognitive impairment
Physical aggression in response to care
Physical aggression spontaneous
Sexual inappropriate/aggression
Physical agitation (exit-seeking, wandering)
Verbal aggression
Verbal agitation
Other
Please identify as specifically as possible the PSYCHIATRIC GOALS OF ADMISSION:
Please elaborate on recent psychiatric, and behavioural history
(including rating scales):
Is substance use an active issue?
Please comment on URGENCY and requested admission period:
Is patient followed by Mental Health Team?
No
Yes Which one?
Do you anticipate certification under the Mental Health Act (date)?
Is patient being referred under Extended Leave?
ADDITIONAL INFORMATION
Draft Jan. 4, 2010
Page 3 of 4
Yes
No
ELDER CARE PROGRAM
MSJ HOSPITAL
REFERRAL FORM- INPATIENT SERVICES
3080 Prince Edward Street
Vancouver, BC, V5T 3N4
Phone: 604.877.8183
Fax: 604.877.8165
SERVICE DESCRIPTIONS
1. Geriatric Psychiatry Inpatient Unit (GPU):
The GPU focuses on assessment and management of older adults 65 years and over, who suffer from lateonset mood, psychotic, and anxiety disorders, especially in the context of concurrent cognitive impairment and
active subacute medical issues.
2. Geriatric Medicine Inpatient Unit:
This service focuses on assessment and management of older adults 65 years and over, who experience
chronic medical illnesses. Four of the beds provide care to older adults who suffer from concomitant acute
medical and psychiatric symptoms at the time of referral.
The following three outpatient services are offered at Mount Saint Joseph Hospital but require a separate referral form.
Please contact these clinics separately (contact numbers listed below)
3. Geriatric Psychiatry Ambulatory Service:
This service focuses on assessment and management of older adults 65 years and over, who suffer from
late-onset mood, psychotic, and anxiety disorders, especially in the context of concurrent cognitive
impairment. Clients should be able to arrange for transportation to and from appointments. A geriatric
psychiatrist will work with other MSJ interdisciplinary team members as appropriate in the outpatient setting
Contact: 604-877-8371
4. Geriatric Psychiatry Ambulatory ECT Service:
This service focuses on outpatient ECT for both index (acute) and maintenance courses. This is a tertiary
service and patients must have a community psychiatrist, Mental Health Team or physician following
relatively closely.
Contact: 604- 877-8142
5. Geriatric Medicine Ambulatory Service:
This service focuses on assessment and management of older adults 65 years and over, who experience
chronic medical illness symptoms. Clients should be able to arrange for transportation to and from
appointments. An interdisciplinary team of health professions, which includes geriatricians and general
practitioners with a focus on elder care, work with clients and caregivers in this outpatient setting.
Contact: 604-877-8371
Draft Jan. 4, 2010
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