Provincial Government Western Cape Metro District Health Services : Home Based Care Referral Form
1. Personal Detail:
Folder No:
Carer :
Surname:
Occupation :
Address:
Name & Initials :
Tel. Nr.:
Id Nr.:
DOB. :
Home Language :
2. Admission Data:
Name of Institution :
Ward:
Date of Admission :
Referred to: (Date & CHC)
Discharge Date :
Doctor :
3. Patient’s Diagnosis & Code:
(Code)
4. Special Investigations:



5. Reason for Admission & Presenting Problem:
6. Discharge Medication:


7. Home Based Care Requirements :
8. Comments :
(Tick appropriate box)
Catheter Care
Tracheotomy Care
Nutritional Support
Wound Care
Pressure Care
Occupational Therapy
Stoma Care
Palliative Care
Physiotherapy
Post Natal Care
Frail Care
Speech Therapy
Psychiatric Follow-up
Nasogastric Care/Feed
Social Support
Equipment Supplies
Health Promotion /
Laborotory Tests /
Investigations
Educational Support
10. Consent of Patient / Family :
9. Follow-up Date :
.................................................................
Print
...................................................................
Signature
1
Section B : Client Assessment
1. Activities of Daily Living
Mobility :
Institution
NGO
Category
Communication :

Moves without help
1

Able to help self

Moves with help
2

Need help

Bedridden, unable to move without help
3

Unable to help self
Institution
NGO
Institution
NGO
2. Personal Hygiene
Toileting:
Washing:

Able to help self
1

Able to help self

Need help
2

Need help

Unable to help self
3

Unable to help self
Mouth Care:
Shaving :

Able to help self
1

Able to help self

Need help
2

Need help

Unable to help self
3

Unable to help self
Haircare :
Eating & drinking capabilities

Able to help self
1

Able to help self

Need help
2

Requires help

Unable to help self
3

Unable to eat & drink
Dressing :
Medication :

Dresses & undresses without help
1

Takes medication without help

Dresses & undresses with help /
needs a reminder to dress / undress
2

Requires help with medication

Unable to dress & undress
3

Unable to take own medication
2
3. Mental Status
(Section B: Continue)
Orientation :
Institution
NGO
Category
Coping Skills :

Knows time, place & people around him / her
1

Able to cope with their emotions

Needs help
2

Requires help with coping with emotions

Unable to tell date, time or place
3

Unable to cope with emotions
Memory :
Institution
NGO
Behaviour :

Memory good / no help needed
1

No difficult behaviour

Sometimes forgets / needs help
2

Sometimes behavioural problems

Serious loss of memory
3

Constant difficult behaviour
Ability to understand instruction / comprehension :

Able to understand - do when asked to do
1

Needs help to understand / comprehend
2

Unable to understand
3
Score
Score
Category
14
1
Independent : Screen , Train family. Referral to other disciplines / support groups
15 – 28
2
Require minimum assistance : Moderate HBC needed
29 - 42
3
Require maximum assistance : Intense HBC needed
Assessor :
Category Description & HB Package
Print Name : ...................................................................
Contact Details : .................................................................................................
Signature & Rank : ...........................................................
.................................................................................................
3
PROTOCOLS
1. Discharge referral protocol.
2. The guidelines on access and provision of treatment supplies to Non Governmental Organisations.
2. HOME BASED CARE DISCHARGE REFERRAL PROTOCOL
OBJECTIVE:
To establish an effective discharge referral mechanism for patients upon discharge from hospital.
SPECIFIC OBJECTIVES:
 To avoid discharge of patients with inadequate community care plans.
 To avoid unnecessary and / or prolonged admission.
 To ensure that appropriate services, equipment, medication and supplies are available at grassroots level.
 To ensure that partners in care know and play their roles to avoid duplication.
 To ensure that partners and key players know and network with each other.
 To ensure that all role players are fully involved and informed regarding the care required.
 To ensure adequate documentation and proper use of referral tool which could effectively be used by a multi-disciplinary team, enabling care to be rendered to the
patient in a holistic fashion.
 To ensure continuum of care at grassroots level.
CRITERIA FOR REFERRAL:
Whenever home based care is considered as an option for continuum of care the following principles should apply:
 The patient’s condition must be stabilized.
 For maintenance of therapy. i.e. post CVA. etc.
 For the continuation of care at home if suitable conditions of care are available e.g. capacity of family to take care of patient and suitable environmental conditions
etc.
 Patient and/or family member’s choice in case of a minor or incapacitated person as a “step-down”.
4
COMMUNITY HOME BASED CARE: DISCHARGE REFERRAL PATHWAY
FROM HEALTH FACILITY TO NGO.
A
TERTIARY
LEVEL
B
SECONDARY
LEVEL
C
DISTRICT
HOSPITALS
D
COMMUNITY HEALTH
CENTRE
E
F
NGO/CBO
HOME
5
GUIDELINES FOR REFERRAL PATTERNS
(Please refer to previous page)
ABC:



Patients requiring home based care are discharged from Tertiary,Secondary, District or Sub-Acute Level of Care.
The referral letter is faxed to Community Health Centre,a copy to patient and a copy is kept in patient’s folder.
The completed CHBC referral form be addressed to the relevant CHC Facility Manager.
D


The patient presents to the CHC and upon receipt of the letter at the CHC, a folder is opened if the patient does not already have one.
This is done to enable the patient to access the necessary RX supplies he/she needs whilst being nursed at home.
E


F





The Facility Manager will in turn refer client to the appropriate NGO HBCO- ordinator.
The purpose of this referral pathway is to facilitate and ensure service delivery of the N.G.O. as well as strengthen communication with the district sister
for purposes of co-ordination and support.
The NGO HBCo-ordinator assesses the client at home.
She/he develops the care plan for the client.
A careworker is then assigned to the client.
The NGO co-ordinator continues to monitor and support the careworker.
The NGO co-ordinator also reports or refers the client back to the CHC if necessary.
NB! In order for clients to access follow-up RX and/or supplies please see protocol on the provision of RX herewith included.
6
2. ACCESS AND PROVISION OF TREATMENT (RX) SUPPLIES
OBJECTIVE:
To ensure adequate and timeous provision of supplies / prescription drugs to.
each client who has been referred for home based care.
OUTCOME:
The referring institution ensures that the prescribed RX / supplies are on code as per essential drug list (E.D.L.)
Clients are provided with adequate supplies of dressing packs / bandages / catheters / catheter bags / nasogastric tubes ect.
PROCESS:

All clients requiring treatment supplies such as dressings, catheters, naso gastric tubes etc, must be a registered client at the C.H.C.

All treatment supplies must be prescribed by the medical officer / Clinical Nurse Practitioner at the Community Health Centre on each individual client’s
prescription chart.
The N.G.O. accesses the supplies for the client, strictly per prescription.
The district sister at C.H.C. level supervises and monitors the administration of all stock and also provides in-service- training to the N.G.O’S on stock
control to prevent unnecessary losses or abuse of stock.
All first time procedures prescribed for the client has to be demonstrated to the
careworkers to ensure efficiency.
Private / Medical Aid clients are expected to access their supplies privately at their own cost, and only qualifies for supplies from the C.H.C. after they
have exhausted their medical aid benefits.
Clients on Medical Aid may however access C.H.C for treatment at Medical Aid tariffs at their own choice.





7