Transition Care Program Referral Form

Bed Based Community Based

Reason/s for referral: ______

TCP goals: ______

Patient/family goals/expectations: ______

Section 1: Referral Source/ Information:

Internal Referral External Referral – Health Network: Referral Date:

Referrer: Contact details:

Referral Reason:

Patient Location/ Ward Ph: Treating Team/Reg Pager:

Admission Date:

ACAS Approval: Yes No

Approved For: Permanent Care Respite Care- High/Low Flexible Care Home Care Package Level:

Delegation Date: / / ACCR Lapsing date:

Discharge Destination (If Known):

Section 2A: Client Details: Marital Status: Country of Birth:

Language/s spoken: Interpreter needed/ not needed (please Circle)

Pension No: Pension Type:

Medicare No: Medicare Expiry:

DVA No: DVA Card Colour: Gold White Blue Orange

GP Name: GP Contact Details:

Section 2B NOK/ VCAT/ EPOA Details:

NOK (1): Mr/Mrs/Ms/Miss Relation to Client:

NOK Address:

NOK Ph: (Home) (Work) (mobile)

NOK (2): Mr/Mrs/Ms/Miss Relation to Client:

NOK Address:

NOK Ph: (Home) (Work) (mobile)

VCAT/ EPOA

VCAT Application Submitted: Yes No Application for Guardianship/ Administration/Both

Applicant Details Name: Address: Ph:

Date Submitted: Hearing Date (If Known):

EPOA/ Administrator: Yes No Name: Ph:

Medical EPOA: Yes No Name: Ph:

Guardian: Yes No Name: Ph:

Advanced Care Plan Yes No Details:

Section 3: Medical Information:

History of Presentation:

Past Medical History:

Ongoing Active Medical/Surgical Issues: Follow up plans/ Appointments:

Care requirements: Bariatric equipment required: ______

______

NWB UL: Duration of NWB :______Ortho review date:______

NWB LL: Duration of NWB :______Ortho review date:______

VRE+ / MRSA: Location of infection: ______

Contact Precautions/ Details: ______

Wounds: Location of wound:______

Dressing Regime/ Frequency:______

Other (Please specify below)

Section 4: Social, Functional and Cognitive Information:

Current Psychosocial Situation:

Lives alone Lives with Spouse/ Family/ Others:

Accommodation Type: House Unit/ Flat Facility: Other:

Accommodation Owner: Client owned Family owned Private Rental Other:

Main Social Supports:

HACC Services/ Frequency:

Home Care Package: Yes No Package Details (level and services):

Case Manager: Yes No Details:

Financial Issues: Yes No Details:

Legal Issues: Yes No Details:

Pre-morbid Current Ongoing Goals Mobility

(eg: ambulation including distance/gait aid, transfers, falls history, endurance)

Occupational Performance

(eg: Personal care, toileting, domestic and community occupations)

Cognition:

(eg: cognitive impairment/ delirium/ dementia diagnosis, MMSE/ RUDAS Score)

Communication

(eg NESB, need for interpreter non-verbal, expressive/receptive deficits)

Nutrition/Swallowing

(eg Diet, swallowing issues)

Section 5: Barriers to discharge

Please comment on any known or potential barriers to discharge including home mods, VCAT proceedings, family conflict etc

______

 Please attach any further reports that may assist with the Transition Care Program referral process or discharge plan; ie: Social work and/or Allied Health VCAT reports, VCAT Medical reports, Neuropsychological reports etc.

 If you are referring from within the networks of Western Health, Melbourne Health or Northern Health - email all referrals to: WHS - Transition Care Referrals

 If you are referring from outside of these three networks, the email address for Western Health Referrals is: [email protected]