Complex Care Center

Complex Care Center 905 Culver Rd O: 585.276.7900 F: 585.288-1381 [email protected]

Dear ,

Thank you for referring your patient to the UR Medicine Complex Care Center. Attached please find a brief questionnaire to complete regarding your patient. It is our goal to make the transition into adult health care settings as smooth as possible for the patients, families, and caregiver circles that you are entrusting to our care. To accomplish this smooth handoff and ensure safe landing of your patient into our care we will utilize your completion of the attached information to begin a conversation with you over the next few months. This information will be reviewed and assessed and then entered into our medical record.

After your patient is booked for their first visit you will receive a notification from our office. We will carefully track that first appointment to ensure that they are able to attend. If your patient does not attend that first appointment we will reattempt outreach and rescheduling in conjunction with your office to ensure that they are able to engage in our care. Once we have achieved a first visit you will receive a summary from that visit and a request for a phone call or communication to complete the process of transfer of care.

In addition to this outreach your patient will receive a request for information.

Once we have received this packet of information from you we will contact the patient or their caregiver from their first appointment. Please complete sections that are pertinent to your patient and feel free to include other pertinent documents. Our team will review this information prior to the patient’s first visit to ensure that all appropriate providers from the Center will engage them on their first arrival.

This document is also available electronically on our website.

Please return to our secure e-mail [email protected] or fax to 585-288-1381

Thank you,

Tiffany Pulcino, MD, MPH Director of the Complex Care Center Assistant Professor of Internal Medicine and Pediatrics University of Rochester Medical Center Patient name: ______

DOB: ______

Address: ______

Best Contact information for patient/family/caregiver: ______

Primary Diagnosis and brief summary of important information regarding diagnosis:

Major secondary diagnosis and summary highlights:

Common Emergent Presenting problems and diagnostic and treatment considerations:

Please fill in all applicable (please consider addition of details about assist devices or therapies): Behavioral concerns:

Communication skills:

Feeding/Swallowing:

Hearing/Vision:

Learning/Education:

Pain Management:

Ortho/MSK:

Respiratory: Sensory:

Mobility:

Allergies/Intolerances to medications:

Current medications, dosage, frequency, when therapy started, discontinued date and if pertinent why:

Active Problem List/Pertinent details: Surgical history: (Please include any indwelling device placement and flush/change schedules)

Active Medical concerns or recent testing that require follow up:

Specialists following patient at time of transfer and planned timing of transition in that provider if applicable:

Hospitalizations in the last year and specific catastrophic events/major challenges you would like us to be aware of: Social/Emotional details helpful to help our team provide seamless care for your patient, please consider additional information about primary caregivers, service providers if available:

Any special/non health related information you want to convey or should we contact you directly prior to appointment?

Please attach immunization records or any pertinent labs/imaging. Best method of follow up communication with you and timing.